Wiki OB/GYN provider and Family Practice provider bill preventive same year

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Commercial ins is denying preventive exam (99396) billed by the OB/GYN because the patient's family practice provider already billed a preventive 5 months ago (Family Practice provider did not do Pap, just physical exam). OB/GYN did a physical exam with pap. They are different specialties - how would you bill this? The OB/GYN did not meet the 7 of the 11 requirements to bill the G0101.
 
Commercial ins is denying preventive exam (99396) billed by the OB/GYN because the patient's family practice provider already billed a preventive 5 months ago (Family Practice provider did not do Pap, just physical exam). OB/GYN did a physical exam with pap. They are different specialties - how would you bill this? The OB/GYN did not meet the 7 of the 11 requirements to bill the G0101.
I assume she is not Medicare so G0101 would not be an option in any case. You need to dig into this insurance policy with regards to coding for an annual. If they state that 9939x can only be billed once a year by any provider, then your only option is an E/M code with the Z code as the diagnosis. Also, it may be time to educate your patient that the ob/gyn is just as qualified to do an complete annual exam and two different providers are not needed.
 
If you do a search, you will find other posts with this same scenario. Some insurances will not pay for preventive, even though different types of exams/specialty. Some will pay only once you submit an appeal letter explaining. Some will automatically pay a preventive by PCP and Ob/Gyn with no intervention needed.
From my perspective as a patient, my PCP and Ob/Gyn do not provide the same service during an annual. While some of the services may overlap, my PCP is not doing a breast exam or PAP. My Ob/Gyn is not recommending when I should have a colonoscopy and doing cholesterol screening.
My opinion is that if both physicians did provide a preventive, that is how it should be billed. I would not advise to change a preventive service to 99202-99215 for the sole reason to have it covered under insurance. I would advise to bill each service with the correct CPT/ICD10 provided. If insurance denies, I would appeal. If the ultimate decision by insurance is that it is not a benefit of the patient's contract, then the patient would be responsible. In a perfect world, the patient should have been informed of this (or at least this possibility) before the services were rendered. However, it is not required if it is a non-covered service.
 
Good morning all,
I have a question on a Well women's exam/AWV/preventive services. Patient made appointment for a annual GYN wellness visit, history was reviewed and the discussion and the decision was made that due to all negative paps and labs that a pap and exam is not necessary (NO exam) So how can we bill these services?

So the only services was documented: the history of past tests (pap) and future test such as mammogram..


I think I found my answer:
 
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If you do a search, you will find other posts with this same scenario. Some insurances will not pay for preventive, even though different types of exams/specialty. Some will pay only once you submit an appeal letter explaining. Some will automatically pay a preventive by PCP and Ob/Gyn with no intervention needed.
From my perspective as a patient, my PCP and Ob/Gyn do not provide the same service during an annual. While some of the services may overlap, my PCP is not doing a breast exam or PAP. My Ob/Gyn is not recommending when I should have a colonoscopy and doing cholesterol screening.
My opinion is that if both physicians did provide a preventive, that is how it should be billed. I would not advise to change a preventive service to 99202-99215 for the sole reason to have it covered under insurance. I would advise to bill each service with the correct CPT/ICD10 provided. If insurance denies, I would appeal. If the ultimate decision by insurance is that it is not a benefit of the patient's contract, then the patient would be responsible. In a perfect world, the patient should have been informed of this (or at least this possibility) before the services were rendered. However, it is not required if it is a non-covered service.
ACOG has been educating insurers for many years on the fact that they do, in fact, act as the primary health care provider for many women. My ob/gyn has always done it all and if yours does not, that is a shame. If the services do not overlap then certainly there would be a need to bill the preventive service twice, but as you say, many insurers do not recognize this at all. For many years we tried to get the CPT Editorial Panel to recognize this difference, but to no avail so we are stuck with trying to convince the payer of a validly executed services that deserves fair reimbursement.
 
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