Annual GYN & Annual Physical not being paid

mnuhfer04

Networker
Messages
37
Location
North Tonawanda, NY
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Hey all, I've been having some issues with getting paid for a patient who was seen for an annual physical and then a few months later seen for an annual gyn. She has a commercial insurance, not medicare. Am I correct that both these visits use 9939(x). The GYN visit is being denied stating that the benefits have been exceeded for the year because a 9939(x) was billed previously for the annual physical. When coding for the annual physical the principal code is z00.00 and for the gyn z01.419. I've appealed the denial and been denied again. If anyone has advise, I would much appreciate it. Thanks!
 

sls314

Guru
Messages
119
Location
Toledo, OH
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Does the patient have a benefit for both an annual physical and an annual GYN visit? That's the first thing I'd check.

It's possible that the patient could have a benefit for only one preventive exam per year - if her insurance policy has a hard limit like that, then it's not a coding issue. It's a benefit issue.
 

nrood

Contributor
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18
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I work in an office that does billing and coding for both PCP and OB/GYN, among other specialties. Big question is, what insurance is it?? Is it a Blue plan?... Highmark, Independence admin, KHPE, BSPC, etc... They want the "S" codes for gynecological preventive visits for both Commercial and Medicare advantage plans. Specifically, the following codes: S0610 for new patient S0612 for established patient. They have a policy. The Blue plans will only pay for 1 99384-99387, 99394-99397 per year. If the PCP billed it already, you will not get paid and vice versa. You can look for a policy for whatever insurance you are having this issue with, if it is not a Blue Plan. If the patient is on a Medicare advantage plan, some of them will follow the Medicare guidelines for preventive gynecological billing, wanting codes: G0101/Q0091. (UPMC, Oscar, for example)
Aetna Medicare advantage plans will pay for 993-- codes. We have never had an issue with both our PCP and Gyn billing 1 each (=2) within the same year, as long as the correct diagnosis is chosen (IE. Z01.419 vs Z00.00).
 
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