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Medicare Annual Breast Exam

  1. #1
    Question Medicare Annual Breast Exam
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    I know that Medicare only pays G0101 and Q0091 every 2 years, however is there a proper code for JUST a yearly breast exam? I've been looking on and ACOG to see if there is anything clearly defined, but can't seem to find anything for just a breast exam (minus the pelvic). Would I bill the appropriate level E/M code and use a specific diagnosis? Also, does anyone have any resources or websites that are specifically geared towards Medicare/Medicaid billing that are easy to navigate and find what you need? Thanks for any input!

  2. #2
    There is no breast exam only Medicare code. They will only pay for a routine breast exam once every 2 years when performed in conjunction with the pelvic exam. If the only reason for the visit is the breast exam I would use the appropriate E/M with the reason for the breast exam as the diagnosis. If the breast exam was "routine" then it will not be payable by Medicare, and there is no routine breast exam diagnosis, you could use V76.10 or V76.19 but I anticipate Medicare would deny this as a non covered benefit.

  3. Default Wellwomen without pelvic
    Pt came in for WWE minus the pelvic exam (rather have it done with female Provider) how do I code the Breast exam only (no other concern or complaint from the Pt) in Family Practice. Do I use code in E/M visit code? or the Preventive cpt code?

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