Wiki Chaperone for a pap

[debdebc]

I have a provider who saw a pt for a pap smear/well woman exam but made this a tertiary dx code. I did ask provider to make the well woman code (Z) code primary but when she did an addendum in chart she put in that a chaperone was not present at the time. Can I still bill out for the well woman exam primary without a chaperone or is this now mandatory. Thank you!

 

[csperoni]

I am unaware of any legal regulations that REQUIRE a chaperone to be present in order to bill a well woman exam. In practice, almost all clinicians follow the practice of a chaperone for any gyn exam (well woman or problem). From my experience, I have yet to encounter a male physician who would perform a gyn exam without a chaperone present, but many female physicians do. Many hospitals/facilities/health systems may require it as part of their own internal regulations and/or bylaws, but that would have nothing to do with whether or not it may be billed. The AMA guidelines state a female chaperone must be present if the patient requests one. I see nothing here that would prevent you billing because another person was not in the room.