Ob-Gyn Coding Alert

Just when you thought you had it all figured out, HCFA has placed another obstacle in front of reimbursement for Pap smear collection. As of April 1, 1999, HCFA purportedly changed Correct Coding Initiative (CCI) edits so that practices could bill for an E/M problem visit, a pelvic and clinical breast examination (HCPCS code G0101) and a Pap smear collection (HCPCS code Q0091) conducted by the same physician for the same patient on the same date of service. That now appears not to be the case.

HCFA did change some Q0091 and G0101-related CCI edits. As set forth in the HCFA Pub. 60B memorandum, effective January 1, 1999, it unbundled the G0101 code (cervical or vaginal cancer screening, pelvic and clinical breast examination) from every E/M service. And as of April 1, 1999, it unbundled the Q0091 code (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) from every E/M service. However, it failed to unbundle E/M services from the Q0091 code. This reversed bundling has caused denials for practices that were apparently following the new billing procedures.

To get around this glitch, simply add a -59 modifier to the Q0091 code, advises Melanie Witt, RN, CPC, MA, program manager for American College of Obstetricians and Gynecologists department of coding and nomenclature. This should over-ride the unchanged CCI edit that associates E/M procedures with the Q0091 code, thereby facilitating payment if the same physician bills for both services on the same date of service.

HCFA historically paid for the collection of a Pap smear (Q0091) every three years for women who did not meet its definition of being at high risk for cervical cancer; annually for those who did. In January 1998, under a congressional mandate to expand preventive benefits, it authorized providers to simultaneously bill for a Pap smear collection (Q0091) and a preventive pelvic and breast exam (G0101) when both are covered. However, if a Medicare patient scheduled for the two preventive procedures also presented with a problem at the same visit, providers could not bill for both the G0101 and an E/M service. A physician could only code for one of the services, or have the patient make another appointment on a different day to be seen for the separate problem.

Under pressure from ACOG, HCFA modified its position on simultaneous billing for preventive and E/M services in two phases. The first, effective January 1, 1999, allowed physicians to bill for both an E/M service and a pelvic screening and breast examination (G0101) performed on the same day. The second phase of modification, effective on April 1, 1999, also authorized reimbursement for collection of a pap smear (Q0091) completed during [...]