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 the same visit as a pelvic and breast exam and an E/M service.

Taking the latest glitch and its associated fix into consideration, to correctly bill for a patient who presented with an abnormal weight loss during a previously scheduled and covered Pap smear and pelvic screening and breast examination visit, a practice would code the following:

G0101 linked to the diagnosis code V76.2 (screening for malignant neoplasmscervix);

Q0091 linked to the V76.2 code, adding a -59 modifier (distinct procedural service) to override the uncorrected CCI edit; and

the appropriate level of E/M service (99211-99215) appended by the -25 modifier (separately identifiable E/M service, same day and physician)linked to the 783.2 (weight loss, abnormal) code.

For women who fall under Medicares high-risk definition and receive annual screenings, the practice would link the pelvic exam and Pap smear collection codes (G0101 and Q0091, respectively) to the V15.89 (personal history presenting hazards to health; other). (For more information on dealing with high-risk care see the May 1999 issue of Ob-Gyn Coding Alert, page 33.)

Even though it now covers screening exams, Medicare still does not accept the generally recognized well-woman check-up code V72.3 (gynecological examination; Papanicolaou smear as part of general gynecological examination; pelvic exam). ACOG has received no indication that HCFA will begin accepting it. I think theyve just decided its too costly to modify their software and they wont be making any changes, says Witt.

Practices that perform annual Pap smears and pelvic exams on patients who do not meet Medicares high-risk definition can bill the patient directly for these services. In years when Medicare does not recognize the screenings, the practice should have the patient sign a waiver acknowledging that Medicare may not reimburse for the service and agreeing to pay for it herself. In this instance, the practice would link both the Q0091 and G0101 codes to the V76.2 code with the Medicare -GA (waiver on file) modifier. After receiving a denial from Medicare, the practice could then bill the patient, Witt advises.

ACOG has communicated with HCFA about the uncorrected CCI edit affecting reimbursement for Q0091 billing, according to Witt. HCFA and its CCI contractor, AdminaStar Federal, are aware of the problem, but the CCI edit probably wont be changed this year due to cost constraints, she predicts. So keep adding modifier -59 until further notice and look for updates in future issues of OCA