I'm looking for documentation that states what an Annual Gynecologic Exam includes. I use Encoder Pro and when I look at the S0610/S0612, the "lay description" has a description of the exam. However, we have payers that use the 9938x/9939x and G0101 for this examination and the lay description is not the same. What I am looking for is a description of the Annual Gynecologic Exam that can be applied regardless of what CPT code the payer requires and whether any problems are inclusive to this code (ie: any problem that is stated/discovered as part of the exam). Thank you.
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Wiki ANNUAL GYNECOLOGIC EXAM
- Thread starter lizbgreen
- Start date
lgardner
Guest
here are the requirements for a breast and pelvis exam https://codingintel.com/g0101-pelvic-breast-exam/:
Pelvic/breast exam G0101 requires 7 of 11 exam elements
Examination of the breast is mandatory to bill G0101- Inspection and palpation of the breasts for lumps, tenderness, symmetry or nipple discharge
- Digital rectal exam
- Pelvic exam including:
- External genitalia
- Urethral meatus
- Bladder
- Urethra
- Vagina
- Cervix
- Uterus
- Adnexa/parametria
- Anus and perineum
nielynco
True Blue
Except for the requirements for G0101, there are no specific requirements outlined via CPT for what constitutes this exam. ACOG has published information about what they consider to be appropriate elements for an annual exam using the 9938x/9939x codes, but not the S codes which were developed by BCBS for their billing purposes. You can access an article about ACOG's take on the exam at: https://www.obgproject.com/2017/03/09/acog-uspstf-guidance-still-role-annual-pelvic-exam/ . It has long been discussed by all parties, that IF a separate significant E/M problem service is provided at the time of the annual preventive exam, both can be billed (with a modifier -25 being added to the problem E/M code), but the documentation tells the story and not every payer will allow both services to be billed.
Thank you. So, if a breast lump is found during an annual exam and an ultrasound is ordered, does this qualified as an additional level/problem visit, in addition to the annual exam, since it was discovered as part of the annual exam? Another example, a patient comes in for her annual exam and would like a renewal of her oral contraceptive, due to amenorrhea, is that considered an annual visit plus a level for an ongoing problem? Lastly, is a new contraceptive script considered part of the annual exam?
When trying to determine if a problem oriented E&M is billable the same visit as a preventive, I'll give the advice I give when trying to determine if E&M is billable with a procedure.
Since the problem oriented E&M will require -25, take your documentation and cross out everything related to the preventive visit. That gives you the "separately identifiable" portion. Is the remaining portion "significant"? If yes, level your E&M with that remaining portion and -25 modifier. If no, then the additional service was part of the preventive visit.
Each of the examples given (breast lump, renew OCP due to amenorrhea, new OCP) MIGHT be a separate and significant E&M depending on the documentation.
Please note - I have encountered some carriers that regardless of the additional problem, as policy, will simply not pay a problem oriented E&M the same day as a preventive.
Since the problem oriented E&M will require -25, take your documentation and cross out everything related to the preventive visit. That gives you the "separately identifiable" portion. Is the remaining portion "significant"? If yes, level your E&M with that remaining portion and -25 modifier. If no, then the additional service was part of the preventive visit.
Each of the examples given (breast lump, renew OCP due to amenorrhea, new OCP) MIGHT be a separate and significant E&M depending on the documentation.
Please note - I have encountered some carriers that regardless of the additional problem, as policy, will simply not pay a problem oriented E&M the same day as a preventive.
Jenetteis
Networker
During an ANNUAL EXAM 40 - 64 POSTMENOPAUSAL visit, the patient complains of painful intercourse, they discuss it, and she is prescribed medication. Is this separately billable or is it part of a well-woman exam? Any advice is appreciated. Thank you
Annual Postmenopausal
Sexually Active: no (she is not active due to pain, but wishes to be)
ROS
Endocrine: Endocrine no endocrine problems. Menopausal no menopausal problems. Sexual painful intercourse.
Physical Exam
Vagina: no discharge, lesions, masses, prolapse, or blood present and atrophy.
Assessment / Plan
N94.10: Unspecified dyspareunia
Discussed options for painful intercourse. Tried Osphena short term but was not on the formulary, so she discontinued. R&B of ERT discussed.
Annual Postmenopausal
Sexually Active: no (she is not active due to pain, but wishes to be)
ROS
Endocrine: Endocrine no endocrine problems. Menopausal no menopausal problems. Sexual painful intercourse.
Physical Exam
Vagina: no discharge, lesions, masses, prolapse, or blood present and atrophy.
Assessment / Plan
N94.10: Unspecified dyspareunia
Discussed options for painful intercourse. Tried Osphena short term but was not on the formulary, so she discontinued. R&B of ERT discussed.
I will assume this is the leftover "separately identifiable" portion. To me, that is significant, but a little stingy on the documentation. How long? How severe? "Discussed options" - what options? In my opinion, this would be billable with -25.