Ob-Gyn Coding Alert

Confusion continues as to just how ob/gyn practices should adapt to the Medicare screening codes, which cover certain breast and pelvic exams. According to Jan Rasmussen, CPC, a coding consultant and instructor for Med-Learn, a practice management training and consulting firm in St. Paul, MN, Many ob/gyn practices are not using codes G0101 and Q0091. They dont even have them loaded in their software. She believes such practices dont understand that Medicare is now paying for these services or know how to use the codes.

Following are some experts responses to five frequently asked questions.

1. What has Medicare agreed to cover? While Medicare has not traditionally paid for preventive services, beginning last year it agreed to pay for pelvic and breast exams in addition to screening Pap smears (which it had covered for several years). The exams are being reimbursed for all Medicare-covered women every three years and annually for women who are of high risk. The Health Care Financing Administration (HCFA) has specifically spelled out what they mean by high risk (see the April 1998 issue of OCA).

As good as it sounds, dont be fooled. Medicare has not suddenly jumped into the business of covering preventive services. Medicare has only agreed to cover an exam of the female genital tract and a breast exam. Thats it. Medicare has not agreed to pay for a full well-woman examination that includes the examination of multiple body systems; blood pressure; looking at the ears, nose, throat; or listening to the lungs or heart tones. Medicare will only reimburse pelvic and breast exams.

However, few well-woman preventive exams are limited to a pelvic and breast exam, says Melanie Witt, RN, CPC, MA, program manager for ACOGs Department of Coding and Nomenclature. You will need to bill the patient for the part of the preventive service not covered by Medicare. Medicare has never covered a full preventive exam and does not now.

2. How should preventive services be reported? When a pelvic and breast exam is performed for a Medicare patient, it should be reported using the HCPCS code G0101. At the same time, Medicare also allows for reporting of the Pap smear (if its the year a patient is eligible for coverage) using HCPCS code Q0091. Both codes should be linked to V76.2 (special screening for malignant neoplasms, cervix). Medicare will not accept the reporting of these services using the CPT preventive medicine codes (99387-99397). If you provided additional preventive services, you can bill these services to the patient using 99387-99397 with a -52 modifier indicating reduced services.

3. Is a waiver necessary? According to Medicare policy, if you are going to bill a patient additionally for a service that Medicare sometimes denies, it is necessary that the patient sign a waiver specific to that service. However, if you are billing a Medicare patient for preventive services not included in the screening pelvic and breast exam, a waiver is not necessary. The reason is this: Medicare has not covered and does not cover preventive services beyond the screening breast and pelvic. Thus, the portion of the exam that includes other body systems, the blood pressure, and listening to the lungs and heart, etc., is not a covered service. Therefore, the waiver is not needed. It may, however, be a good idea from a patient-relations standpoint to let the patient know in advance that payment for the non-covered service will be due at the time of the visit.

4. What about supplemental insurance? If the patient has supplemental medical insurance, it may cover the portion of the preventive service not covered by Medicare. In this case, you would submit a claim to the supplemental carrier using the 99387-99397 codes with the -52 modifier indicating the reduced services. Some supplemental carriers may request to see a denial from Medicare, and Witt says you may need to submit the preventive medicine codes to Medicare in addition to the HCPCS codes so a rejection can be shown to the supplemental carrier.

5. Can the GO101 and an E/M be reported for the same day? Yes, both a G0101 and an E/M can be reported on the same day. As reported in the February 1999 issue of OCA, a recent HCFA program memorandum (HCFA Pub. 60 B) states: Effective with the CCI update for Jan. 1, 1999, G0101 is allowed with an E/M visit if the visit is separate from the G0101 service. When both services occur at the same encounter for distinct reasons, modifier -25 should be utilized on the claim. As of April 1, 1999, the same applies to the Q0091.