Ob-Gyn Coding Alert

Question: An established Medicare patient comes into the office for a problem visit and tells the ob-gyn that she hasn't had a Pap smear in several years. The ob-gyn decides to do one at this visit. How should I report this?

Maine Subscriber

Answer: You should report Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the Pap collection linked to a diagnosis of V76.2 (Special screening for malignant neoplasms; cervix).

For the problem visit, you would report an office visit code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). You must add modifier 25 (Significant, separately identifiable evaluation and management service on the same day of a procedure or other service) to the E/M code, so that Medicare will pay Q0091.

If the ob-gyn performs a pelvic exam at the same visit (and it is not related to the problem she presents with), you can also bill for that using G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) in addition to the problem E/M service and the Q code.