Ob-Gyn Coding Alert

V72.31 Joins the Ranks of Other Medicare Low-Risk Patient Codes

Published on Tue Mar 01, 2005

You should only report V72.31 for a full gynecological exam

When you get ready to report an annual Pap smear for a low-risk Medicare patient, you'll get to use V72.31 - the same code commercial payers urge you to use.

Medicare released a Jan. 21 transmittal stating that it is finally correcting the frequency edits for Q0091 (Screening Papanicolaou smear ...) (see "When Medicare Incorrectly Reimburses Q0091, You're Left Holding the Bag" later in this issue for more information), and as of July 1, 2005, you may also use v72.31 (Routine gynecological exam).

Use V72.31 for Routine Gynecologic Exam

Code V72.31 shouldn't be entirely new to you. Although commercial payers sometimes follow Medicare's lead when setting coding policies, most have always accepted this diagnosis code when the ob-gyn performs a full gynecological examination.

In other words: You would use V72.31 for the routine gynecologic examination that either does or does not include a Pap smear.

"If Medicare wants us to use V72.31, then that's fine by me - as long as they get it right," says Christine Dubois, CPC, the coding coordinator and compliance office for Western Mass Physician Associates in Holyoke, Mass.

This ICD-9 code joins the other applicable diagnosis codes that Medicare will accept for low-risk patients:

V76.2 - Special screening for malignant neoplasms, cervix

V76.47 - Special screening for malignant neoplasms, vagina

V76.49 - Special screen for malignant neoplasms, other sites (Note: You should use this diagnosis for women without a cervix.)

You can now use V72.31 as another option, but remember, you can only use this code if the ob-gyn performed a full ob-gyn exam.

Prepare for 2 Reactions

You can expect two reactions to this change - resistance and gratitude.

On one hand, you may have a hard time re-educating your staff that they have another code out there to use. "To be honest, it will be difficult for providers to use V72.31 because they've been learning in many coding clinics that they should use the other code," says Sue Morrison, CCS-P, a coding and billing specialist at Sparta Community Hospital, Quality Healthcare Clinics in Sparta, Ill.

But on the other hand, you now have the freedom to follow the exact rules commercial payers follow for a full ob-gyn exam. "This will make coding annual exams much easier for our practice, because the medical staff find it hard to differentiate between Medicare coding and commercial insurance code," says Arlene Ferguson, CPC, insurance specialist with Tacoma Women's Specialists in Tacoma, Wash.

"We're pleased. The previous Medicare diagnosis codes weren't as accurate as we would've liked," says Cindy Foley, billing manager at Upstate Gynecology Group PC in Syracuse, N.Y.

Don't Overlook G0101 and Q0091

A change in diagnosis code does not mean that there's a change in the procedure codes you should use. You should still report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the breast and pelvic exams. When the ob-gyn also obtains a Pap smear, you should use Q0091.

Remember: You can also report a new or established patient E/M code (99201-99215), but the ob-gyn must have documented a separate and distinct E/M service to warrant the attachment of modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Heads-Up: High-Risk Means Annual

If a Medicare patient is high-risk, you should be able to report Pap smears annually - and receive reimbursement for them.

To classify a patient as high-risk, you will likely report V15.89 (Other specified personal history presenting hazards to health; other) for medical jurisdiction of a screening Pap smear. But your diagnoses coding doesn't end there. You must supply a secondary code to explain why the patient should be considered high-risk. Choose from the following list:

history of HIV (V08 or 042)

history of sexually transmitted diseases

five or more sexual partners (V69.2)

began sexual activity before 16 years of age (V69.2)

diethylstilbestrol (DES) exposure (760.76)

seven years without a Pap smear (V15.89)

absence of three consecutive negative Pap results (795.0x).