Wiki Medicare well woman exam diagnosis code

[SWall]

I have been getting a lot of denials for Z01.411 as the primary diagnosis code for Medicare well woman exam CPT code G0101.


If a patient that is currently being treated for cancer and taking a chemo tablet orally does that consider them to be high risk? If so, what primary diagnosis code would you put for G0101? Because I have put the Z01.411 and I am getting several denials. Would Z91.89 be correct for a primary diagnosis code

 

[nielynco]

I have been getting a lot of denials for Z01.411 as the primary diagnosis code for Medicare well woman exam CPT code G0101.


If a patient that is currently being treated for cancer and taking a chemo tablet orally does that consider them to be high risk? If so, what primary diagnosis code would you put for G0101? Because I have put the Z01.411 and I am getting several denials. Would Z91.89 be correct for a primary diagnosis code

If you have not already done so, please access the following Medicare information: https://www.cms.gov/files/document/mln909032-screening-pap-tests-pelvic-exams.pdf

If the patient is currently being treated for cancer, she no longer needs a screening Pap/pelvic exam so G0101 would not be correct. If the test is being done to continue surveillance after a diagnosis of cancer, it is a diagnostic, not screening test and so you would simply bill the test (or the lab bills) and the service is a regular E/M service.

The purpose of this code is to SCREEN for the presence of cancer in a patient once every 2 years if she is low risk or once every year is she is high risk. And to be high risk there must be evidence (based on the medical history or other findings) that the patient is at high risk for developing cervical or vaginal cancer and the patient's physician (or authorized practitioner) recommends they have the test more frequently than every 2 years, or the patient is of childbearing age and had a screening Pap test or pelvic exam during any of the previous 3 years indicating the presence of cervical or vaginal cancer or other abnormality. This article indicates the diagnoses that are acceptable and of course Z07.411 is listed, but the other conditions may not have been met.

 

[SWall]

If you have not already done so, please access the following Medicare information: https://www.cms.gov/files/document/mln909032-screening-pap-tests-pelvic-exams.pdf

If the patient is currently being treated for cancer, she no longer needs a screening Pap/pelvic exam so G0101 would not be correct. If the test is being done to continue surveillance after a diagnosis of cancer, it is a diagnostic, not screening test and so you would simply bill the test (or the lab bills) and the service is a regular E/M service.

The purpose of this code is to SCREEN for the presence of cancer in a patient once every 2 years if she is low risk or once every year is she is high risk. And to be high risk there must be evidence (based on the medical history or other findings) that the patient is at high risk for developing cervical or vaginal cancer and the patient's physician (or authorized practitioner) recommends they have the test more frequently than every 2 years, or the patient is of childbearing age and had a screening Pap test or pelvic exam during any of the previous 3 years indicating the presence of cervical or vaginal cancer or other abnormality. This article indicates the diagnoses that are acceptable and of course Z07.411 is listed, but the other conditions may not have been met.

Thank you so much! I really do appreciate your detailed response.

I also have another question in regards to Medicare Well Women exams for pt's 65+. If a pt has documentation of a breast exam and vaginal exam but NOT a pap smear would you bill a G0101 or a office e/m code (99202-99215) with dx code Z01.419-Z01.411?

 

[nielynco]

Thank you so much! I really do appreciate your detailed response.

I also have another question in regards to Medicare Well Women exams for pt's 65+. If a pt has documentation of a breast exam and vaginal exam but NOT a pap smear would you bill a G0101 or a office e/m code (99202-99215) with dx code Z01.419-Z01.411?

G0101 represents pelvic (plus breast exam if performed) examination, not a pap smear. The requirements for G0101 is the documentation of the examination of 7 of the 11 elements listed by Medicare to meet their requirements. If a pap smear is also performed, you would additionally code Q0091, if not you bill only G0101.