Wiki Diagnosis Codes for Annual, Pap smear, hysterectomy, hx cancer

[JessicaLR]

Which diagnosis codes do you use for Preventative GYN visit 993xx and 88175 Pap smear, patient has had a hysterectomy due to endometrial cancer and vag Pap is done. Would Z01.419, Z90.710, Z85.42 be correct?

Would the same diagnosis codes used for this for both commercial insurance or Medicare?

 

[jhanmer83]

For all insurance except Medicare, I use the routine preventive 99381-99397. I use diagnosis Z01.419 mostly, with the occasional Z01.411. Z00.00 is required for Medicaid. They will deny Z01.419. For Medicare, I use G0101 and Q0091 with Z01.419, Z12.4 or Z01.411, unless they are high risk.

Medicare covered codes for low risk: Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.80
Medicare covered codes for high risk: Z77.22, Z77.9, Z91.89, Z72.89, Z72.51, Z72.52, and Z72.53.

I find that if Z72.51 is the only code, Medicare has been denying 88175 for dx not covered.

Since the patient is s/p hysterectomy, I would use the diagnosis for encounter for screening for malignant neoplasm of vagina, with a secondary code for acquired absence of both uterus and cervix (if that's what was removed. There are other codes for partial absence, etc.)

 

[Camila77]

Please I need some help with this. if a patient comes for a Pap smear with his PCP and there is no any other complains should I use Q0091 since the EM code can not be use because there is no any other diagnosis o complains?? Or theses Codes Q0091 and G0101 should be only use with medicare patients?

 

[csperoni]

Please I need some help with this. if a patient comes for a Pap smear with his PCP and there is no any other complains should I use Q0091 since the EM code can not be use because there is no any other diagnosis o complains?? Or theses Codes Q0091 and G0101 should be only use with medicare patients?

Basically, it depends what services you are providing. Did the PCP perform an annual well woman (breast exam, pelvic exam, contraception discussion, family planning, screening, counseling, etc) in addition to the PAP? If so, then 99381-99397 are appropriate E/M codes with dx Z01.419, Encounter for gynecological examination (general) (routine) without abnormal findings (or Z01.411 if there were abnormal findings). If the clinician just took the PAP sample without providing additional services, then you should not bill for them.
G0101 I have seen covered by some commercial carriers, but most ob/gyns are billing the 99381-99397 instead for an annual well woman.
Q0091 is used by Medicare as well as commercial carriers. Some payors will bundle the Q0091 into an E/M.

Here's a great link going further into detail https://codingintel.com/billing-pap-smear/

I will make a side note since it is the PCP, many insurances will only pay 1 well exam per year to PCP. If the patient already came in within the year for annual well exam and you already billed 99381-99397, you may not get it covered a second time. POSSIBLY with appeal and showing the diagnosis of gynecological exam.

I will make another side note that in my area, it would be highly unusual for a PCP to do a PAP (like I've never seen it once in 16 years highly unusual). They would refer the patient to an ob/gyn and wouldn't even have the stirrups, speculum, PAP brush, etc. if the patient requested the service. In other parts of the country (particularly more rural areas with less access to ob/gyn care), it is a more common practice.

 

[pfskdj@yahoo.com]

The practice I work for is running into a situation where the commercial insurance carriers will only pay for one physical annually but the patient has a PCP that does not perform Gyn exams. In this scenario how do you suggest we code for the pelvic, breast and/pap when the patient has already had an annual physical within the year? Currently we are using 9938X - 9939X for both services.

 

[csperoni]

The practice I work for is running into a situation where the commercial insurance carriers will only pay for one physical annually but the patient has a PCP that does not perform Gyn exams. In this scenario how do you suggest we code for the pelvic, breast and/pap when the patient has already had an annual physical within the year? Currently we are using 9938X - 9939X for both services.

Just to clarify - PCP is not doing well woman exam. PCP (internal med, fam practice, etc) is doing a general annual physical.
Pt is then coming to you (obgyn) for the well woman. 99383-99397 is the appropriate coding for the obgyn with Z01.419 or Z01.411 (and of course any other applicable dx for the patient.) Most carriers have appropriate claim checks in place to recognize the separate specialty and/or diagnosis. If a claim gets denied due to the 2 preventive services in a year, typically a phone call or online request will resolve it. Otherwise, an appeal letter will be required. While it is 2 preventive services in a year, the scope of those 2 services are very different.