Wiki Well woman exam with abnormal results and biopsy

[AlisonFaught]

I am a new coder and the ONLY coder at my new job, so I have a lot of questions! Here is one in particular:

A patient came in for a yearly female exam and the NP discovered lesions on the labia and a shave biopsy was performed x2.

Can I charge for both the exam (99214-25) with diagnoses Z01.411 and D39.8 and the biopsy (11305 and 11305-59) with D39.8? I read an article on AAPC.com entitled "Know When to Bill E/M with a Minor Procedure" that basically states that if the need to perform a minor procedure is determined as a result of an E/M service then both can be reported, but I just wanted to get other coders' opinions. Insurance is Medicare, btw.

 

[CodingKing]

Please review medicare preventive services chart as 99214 is not billed for a female exam for Medicare. Only specific preventive services are covered. Annual physical is not one of them, for example low risk
breast and pelvic G0101 is only once per 24 months: https://www.cms.gov/Medicare/Preven...ntive-services/MPS-QuickReferenceChart-1.html
In addition to the code for the preventive service would be the codes for the biopsy. E&M will be inclusive in the biopsy codes as its incidental finding from the pelvic exam. The decision to perform a minor procedure is included in the minor surgical procedure
You will need to wait for the results or use a sign/symptom DX. D39.8 can only be determined by a pathologist. Its not the same as we don't know yet.

 

[katemae84]

You can still bill for the G0101 without the breast exam as long as it meets Medicare's NCD, which can be found here:
https://www.cms.gov/medicare-covera...ails.aspx?NCDId=185&ncdver=3&bc=AgAAgAAAAAAA&
Keep in mind that if the Medicare patient is low-risk and having this done more frequently than Medicare coverage allows, then your office should be having the patient sign an ABN, otherwise you won't be able to bill the patient for the non-covered G0101.
Also, the biopsy codes will be site specific to the vulva rather than normal skin biopsy codes. 56605 for the first lesion, add on code 56606 for the second.

 

[AlisonFaught]

Please review medicare preventive services chart as 99214 is not billed for a female exam for Medicare. Only specific preventive services are covered. Annual physical is not one of them, for example low risk
breast and pelvic G0101 is only once per 24 months: https://www.cms.gov/Medicare/Preven...ntive-services/MPS-QuickReferenceChart-1.html
In addition to the code for the preventive service would be the codes for the biopsy. E&M will be inclusive in the biopsy codes as its incidental finding from the pelvic exam. The decision to perform a minor procedure is included in the minor surgical procedure
You will need to wait for the results or use a sign/symptom DX. D39.8 can only be determined by a pathologist. Its not the same as we don't know yet.

Thanks for your reply! NP did not document a breast exam, only a genital exam. So, I don't think I can report G0101? I guess I will just report the biopsies - and I got the dx D39.8 from the pathology report

 

[AlisonFaught]

You can still bill for the G0101 without the breast exam as long as it meets Medicare's NCD, which can be found here:
https://www.cms.gov/medicare-covera...ails.aspx?NCDId=185&ncdver=3&bc=AgAAgAAAAAAA&
Keep in mind that if the Medicare patient is low-risk and having this done more frequently than Medicare coverage allows, then your office should be having the patient sign an ABN, otherwise you won't be able to bill the patient for the non-covered G0101.
Also, the biopsy codes will be site specific to the vulva rather than normal skin biopsy codes. 56605 for the first lesion, add on code 56606 for the second.

We definitely need to work on getting more ABNs signed. Do I need to put a -25 on the G0101?

 

[katemae84]

Yes!