Question Do I or don't I? 99396, G0101, Q0091 (women's wellness exam, pelvic/breast exam and pap)

lbc2of3

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I am not much for OB, just had it tossed on my lap. No experience with it but I am familiar with the preventive exam codes, and I am researching as of course I have some charts with providers billing for preventive 99396, and then the medicare carve out hcpcs codes for pap. I struggle because the exam portion of a "preventive" cpt includes an age and gender appropriate exam....I find information all over the place to code it, not to code it, frankly I am losing it. Can anyone offer up some guidance for solid backed information on this? Just because something doesn't hit a CCI doesn't make it okay to bill it if guidelines would have you believe otherwise....any advice would be absolutely graciously appreciated.
 

bkegler

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If they have Medicare and a breast/pelvic exam and pap were done, absolutely carve them out with the G0101 & Q0091 codes. Medicare does NOT cover the preventive CPT codes but does cover these G & Q codes once every 24 months (once every 12 months for high risk pts). It is recommended to have an ABN on file for these services as well.
 

lbc2of3

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If they have Medicare and a breast/pelvic exam and pap were done, absolutely carve them out with the G0101 & Q0091 codes. Medicare does NOT cover the preventive CPT codes but does cover these G & Q codes once every 24 months (once every 12 months for high risk pts). It is recommended to have an ABN on file for these services as well.
Thank you, this was my thought but when dealing with strictly commercial, would these services then not be considered part of the preventive gyno exam?
 

nielynco

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Thank you, this was my thought but when dealing with strictly commercial, would these services then not be considered part of the preventive gyno exam?
Yes. If this is commercial insurance and not a Medicare beneficiary, the pelvic and pap would be bundled by the payer as an all inclusive service. The G and Q codes were developed by Medicare and Medicare billing purposes although some Medicaid payers have also adopted them. As they say "know thy payer" in order to get paid correctly.
 

lbc2of3

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Yes. If this is commercial insurance and not a Medicare beneficiary, the pelvic and pap would be bundled by the payer as an all inclusive service. The G and Q codes were developed by Medicare and Medicare billing purposes although some Medicaid payers have also adopted them. As they say "know thy payer" in order to get paid correctly.
Thank you so much for your response, I appreciate the input, this was my thought I was just losing my mind over the conflicting information I have found, but this confirms my thought process and understanding. thank you again!!!
 
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