Special HCPCS Codes Get Optimal Pay Up for Gyn Exams
Published on Sat Jul 01, 2000
Nugget: Family practices will get the reimbursement to which they are ethically entitled by correctly assigning G0101 and Q0091 for gynecological screening exams in Medicare patients.
Many family practices do not receive the payment they deserve for screening Pap smears or breast and pelvic exams because coders fail to assign proper codes for Medicare patients. These individuals include not only elderly women, but also younger patients eligible to receive Medicare benefits those who may be physically or mentally disabled, for instance, or those who suffer from permanent kidney failure.
After the Balanced Budget Act of 1997, Medicare began to cover increased preventive services and added two codes for gynecological screening exams G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory).
Medicare provides coverage for these services routinely once every three years. The screening exams may be covered more often if the patient is of childbearing age. In addition, more frequent screenings and Pap smears are allowed for women of any age who are deemed to be at greater risk for cancer.
These codes are particularly applicable to family practitioners, as well as internists and ob/gyns, points out Jan Rasmussen, CPC, coding consultant and instructor for Med Learn, a medical practice management training and consulting firm based in Minneapolis/St. Paul, Minn. However, when I perform chart reviews, I often see that they are not billing for these services for their Medicare patients. Or, if they are, they are not including the proper documentation.
This failure to report or improper reporting results in a significant amount of lost revenue for family practices, she adds.
When and How to Assign G0101
Clinical breast and pelvic screening examinations are covered by Medicare Part B when ordered by a physician, as long as they meet specific requirements, according to HCPCS 2000. The requirements include:
the patient has not had a test during the preceding three years;
the patient is a woman of childbearing age; or
there is evidence, on the basis of medical history or other findings, that she is at high risk of developing cervical cancer and her physician (or other authorized practitioner) recommends that she have the test performed more frequently than every three years.
High-risk factors for cervical and vaginal cancer are defined as early onset of sexual activity (younger than age 16), multiple sexual partners (five or more in a lifetime),
history of sexually transmitted disease (including HIV infection), fewer than three negative or no Pap smears within the previous seven years, and DES-exposed (diethylstilbestrol) daughters of women who took DES during pregnancy.
For the screening breast or pelvic exam services to be covered [...]
