Primary Care Coding Alert

When billing for a preventive medicine service, gynecological examination and Pap smear, family physician (FP) coders can sacrifice up to $75 in revenue for each case, leaving many practices not feeling good. But you may find an easy remedy for your woes: Know what the codes include, serve thy payer, and explore HCPCS level-two codes. With various insurers requiring a multitude of methods to report an annual gynecological examination, you face a real challenge, says Cathy Gasiewicz, RHIT, system compliance coordinator at Botsford Clinic in Farmington Hills, Mich. But, what many FP coders overlook are the HCPCS level-two national codes, which include G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination), Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), S0610 (Annual gynecological examination; new patient) and S0612 ( established patient). Although Medicare does not cover the S codes, the Blues float away with covered alternatives. $75 Is at Stake To navigate through the coding maze, you should understand why so many options exist. CPT does not provide a separate code for a gynecological examination, which many FPs provide as part of a preventive medicine service (99381-99397) for a female patient. Therefore, you may fall into the trap of failing to separately code a breast and pelvic exam and Pap smear when it is appropriate to do so. Each of these services deserves separate coding for Medicare purposes. Failing to do so can sacrifice almost $75 in Medicare revenue, based on a $36 breast and pelvic exam fee and $39 Pap payment (the Medicare Physician Fee Schedule grants 0.97 relative value units to G0101 [0.97 x 36.79 = 35.69]) and 1.06 RVUs to Q0091 [1.06 x 36.79 = 39.00]). (Your physician may want to set separate fees forthese services to facilitate billing for them separately, when appropriate.)

Part of this undercoding loss comes from the ambiguity implied in the preventive medicine codes. Codes 99381-99397 refer to a comprehensive preventive medicine E/M. A comprehensive preventive medicine E/M is not, however, the same as the comprehensive examination required in E/M codes 99201-99350, CPT states. Codes 99381-99397 instead reflect an age- and gender-appropriate history/exam, which creates some variability, says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. Know Your Options To bill these additional services, you must follow each payer's rules. So let's look at three common guidelines: Medicare, Blue Cross/Blue Shield (BCBS), and other third-party payers. The King Has Annual Rules The most copied insurer, Medicare, requires G0101 for breast and pelvic exams and Q0091 for the Pap smear. Medicare allows billing both services at a frequency based on the patient's risk [...]