Modifier for Q0091 and G0101 with E&M 99214

lorettac

Networker
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Miramar, Florida
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Need help please!
Patient came to office for follow up and also performed pap smear (routine pap). Claim was submitted with
99214 with modifier 25 with Dx N64.89, J30.9, M25.529, Z01.419
Q0091 with Dx Z01.419 (without modifier)
G0101 with modifier 59 with Dx Z01.419
Avmed denied Q0091 as the procedure code is not paid separately and G0101 was also been denied due to the procedure code is inconsistent with the modifier or a required modifier is missing.
Please advise, if the modifier 59 should be appended to Q0091 and leave G0101 without modifier? Thank you!
 

mitchellde

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What was the reason for the encounter? was it a well woman a full preventive? you have used mainly unspecified diagnosis codes and a well woman with no abnormal findings. It would help to know the actual reason for the encounter and where the diagnosis codes came from.. Also you would not use a modifier with either the Q or the G code. From what I can guess the 99214 is probably not the correct code, however that is just a guess based on how unspecified the codes are. A note would help the review.
 

lorettac

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Thanks Debra, as per documentation, patient came for allergic rhinitis, elbow pain, calcification of breast, therefore 99214 was submitted for the visit. And a pap smear was performed on the same visit, for screening purpose not for any abnormal reason. Thanks in advance.
 

mitchellde

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I would not code it as a well woman encounter in that case. Just use the Z12.4 for the screening and the Q0091 for the screening PAP collection.
 

daedolos

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Would you report a modifier on Q0091?

Peace
?_?
Any guidance on United Healthcare policy? I was only able to find senior plan policy and none for commercial, non-senior. Thanks in advance.
 

SharonCollachi

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Would you report a modifier on Q0091?

Peace
?_?
Any guidance on United Healthcare policy? I was only able to find senior plan policy and none for commercial, non-senior. Thanks in advance.
What are you looking for the modifier to do?

If you are performing a preventive visit (I'm not considering any information further up in the thread, as that was three years ago, and I don't know if it applies to your question), then the pap smear is part of the visit. Here is some info:




What do I code when I do a pap smear?
So, what does a gynecologist or primary care practitioner report for doing a pap smear at a visit? The answer depends on the type of service. And, there are two HCPCS codes for screening services, listed below.

Pap smear during a problem oriented visit

If a patient presents with a condition or complaint, such as discharge, pelvic pain or dysfunctional uterine bleeding, and the practitioner does a pelvic exam and collects a pap smear, bill an E/M service only. Select the level of E/M service based on the key components of history, exam and medical decision making, or time, if counseling dominates the visit.

Do not report Q0091 for obtaining a diagnostic pap smear performed due to illness, disease or a symptom.

For example, the patient presents with dysfunctional uterine bleeding and as part of the work up, the clinician performs a pap smear. The pelvic exam that the provider does is part of the E/M service, and can contribute to the level of service that is billed. There isn’t a code to separately bill the pelvic exam that is part of a problem-oriented visit, but there are exam elements defined in the Documentation Guidelines for a GYN exam. It would be incorrect to bill the HCPCS code Q0091 for obtaining a screening pap smear, because the purpose of the visit and the pap is not screening

Pap smear during a preventive medicine services for a commercial patient

If the patient presents for a preventive medicine service, the pelvic exam is part of the age and gender appropriate physical exam, as described by CPT® codes in the 99381—99397 series of codes. However, for a screening pap, the HCPCS code for obtaining the screening pap smear, Q0091 may be used. Although this is a HCPCS code developed by Medicare for Medicare patients, many commercial payers recognize the code. Do not bill G0101, pelvic and clinical breast exam, on the day of a CPT preventive visit. CPT codes 99381–99397 include an age and gender appropriate history and physical exam. Billing G0101 would be double billing for that portion of the exam.

G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination (Ca screen; pelvic/breast exam )
Q0091 Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory (Obtaining screen pap smear)
Pap smear during a Medicare wellness visit

Medicare doesn’t pay for routine services, but does pay for a cervical/vaginal cancer screening with a breast exam. (Medicare pays for wellness visits, not discussed here. There are articles and videos on CodingIntel that discuss the welcome to Medicare visit and initial and subsequent wellness visits.) A patient can have this service annually with a high risk diagnosis and every two years with a low risk diagnosis. High and low risk diagnosis codes are listed in the cheat sheet below. (Click image to enlarge).


Click to enlarge
A Medicare patient may have a pelvic and clinical breast exam performed alone as the only service performed that day, at the time of a problem oriented visit or on the day of a wellness visit. There is a HCPCS code for this, G0101.

Do not bill HCPCS code G0101 in addition to a preventive service reported with CPT® codes 99381—99397. Those codes include an age and gender appropriate physical exam and if needed, the pelvic and breast exam is part of that service. Most commercial payers do not recognize G0101.

G0101 requires a breast exam and a total of 7 of these exam elements:

  • Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge
  • Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses
  • External genitalia
  • Urethral meatus
  • Urethra
  • Bladder
  • Vagina
  • Cervix
  • Uterus
  • Adnexa/parametria
  • Anus and perineum
There is no code for performing the breast exam alone on a Medicare patient who does not need the remainder of the screening exam elements.

Summary of pap smear billing guidelines
  • If using CPT® preventive medicine services, and also performing a screening pap smear report a code in 99381-99397 series and Q0091.
  • If using E/M codes for a symptom or condition and practitioner also obtains a pap smear report only the E/M service. Do not report Q0091 because it is for obtaining a screening test.
  • Use G0101 and Q0091 for Medicare patients receiving a screening pelvic and breast exam and having a screening pap smear. There are frequency limits for this service.
Updated 12/21/2019
 
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