Wiki Question about G0101 vs physical code for commerical insurance

[aarnold13]

Hello all! This is my first post on these forums and I am eager to hear what everyone has to say

We have a nurse practitioner here that does a lot of yearly female physicals. She feels that when she does a yearly physical she needs to review at least 10 body systems and do a complete review that is comparable to an H & P pre-op consult. When I read in the CPT book in preventative medicine (99391-99397) I understand that the yearly physical just needs to be age appropriate. This is pretty vegue and doesn't fully explain what all needs to be included in a preventative medicine visit. She is wanting to just use G0101 for the pelvic and breast exam and then Q0091 and 88142 for the pap collection.
I guess I am asking if anyone can give me insight on what she would need to include in her visit to be able to charge the physical code instead of the G0101 code.

Thanks!
Angie

 

[pamtienter]

When a patient (male or female) is in for a preventive physical, it is up to the practitioner to perform an age appropriate exam then a CPT from the 99381-99397 range is billed. There is nothing that says how many body/organ systems must be examined but it is supposed to be "comprehensive".

When the patient is female, a pap/pelvic may or may not be performed at that visit. That doesn't change the fact that one of those CPT codes can be billed. The commercial payers in our area bundle G0101 into the preventive CPT so I would check with them to see what they want.

We bill G0101 only when a female patient has had their preventive visit and then come back at a later date for the pap and pelvic part of the exam.

 

[aarnold13]

Thank you!

Pam-
Thank you for your reply. I do know not to bill the preventative e/m at the same time as the G0101, that it is one or the other. I guess I was just thinking that our nurse practitioner is kinda cheating herself when she only bills the G0101 because she doesn't fully understand what needs to be included in a physical. I have tried doing research online for more specifics of what should be included with preventative check ups but have not come up with much.

 

[pamtienter]

I was just putting the preventive CPT info in because I agree that she is cheating herself. G0101 would only be for the pap and pelvic portion so what about the work she did to probably check their heart, lungs, etc? I think she should use the preventive CPT codes. Maybe she could talk with the others in the clinic and get from them what they do in their preventive visits? I don't know of anywhere that says what has to be included. I've just heard that it's up to the practitioner to determine that. Maybe from their professional organization.