Wiki OB/GYN vs Family Practice wellness exams

[Narfitygirl]

We have recently run into an issue in which a patient presents to our practice for their routine GYN exam with pap. As an GYN, we bill out 9938X=9939X with Z01.419/411. Lately, we have been receiving denials stating the patient was seen by another physician for these services (Internal Med/Family Practice). The patient's are insisting they did not have a pap smear, but the insurance company continues to deny our claims. I imagine the FP/IM practices are using the same preventative codes (9938x-9939x) which I believe is appropriate. Here is my question, is there a different CPT or ICD10 code that should be utilized for a preventative visit WITHOUT pap/pelvic exam the IM/FP docs should be using? We cannot submit the G/Q codes as they are MCR codes and not payable by most commercial plans.

 

[csperoni]

MOST commercial plans will cover both a preventive by PCP and a well woman preventive by ob/gyn. Each provider uses the appropriate Z code (usually Z00.0X for PCP and Z04.41X) to help distinguish. Most carriers will process it correctly the first time. Some will require an appeal. Some will simply not pay for a second preventive visit. Some (usually only MA plans) won't pay for the second preventive, but will pay for G0101/Q0091 - and if so, may want cervical cancer screening codes instead of Z04.41X.
I suggest creating a spreadsheet for your practice to help better inform your patients prior to services being rendered, and get clean claims out the door.

 

[TThivierge]

Hi Narftygirl
Why are the female patients returning for a pap if one already done for the year? There must be a medical problem. The physician needs to document what ever the problem is in giving the proper diagnosis to bill. Not always dx Z01.41X especially if the payers algorithms picked that up already for the year. If it needs to be done again is the reason and use modifier KX if pap done again. KX is medical necessity again illness. Also ask the patient last time had a pap? Most women do not want to get pap again unless a problem. Well that is how I feel. Anyway, is the medical problem related to rash R21 or some type of STD? Is it related to Menstrual Migraine G43.82 & N94.3 or Polyp dx N84 or cyst in the vault area dx N75.9 or DO of the Uterus N85.9? PID dx N73 with dx & B95-B97 is possible too. Or Excessive Mensuration dx N92 or Irregular menstruation dx N92.6 or Ovarian Dysfunction dx E28.1 O Chronic pelvic pain R10.31 & G89.29 or N39 UTI, or N94 & R25.2dx Or rare menstruation problem dx N91 or L29.2 itchy vulva lips? The following dx can be related to STD dx Z11.3 ,Z11.4 and check out dx A50-A56 but need lab results as proof of STD infection. Also check the dx blocks of R87 and R82 reasons labs taken for OB/GYN problems.
Try guiding the providers using the ICD10 manual and use other Eval Mgt CPT codes related to new or est. visits.

Well hope I helped your dilemma .

Lady T.