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United Healthcare CPT 99397

  1. #1
    Default United Healthcare CPT 99397
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    Is anyone familiar with United Healthcare denying a 99397 dx V70.0 routine medical exam as max met.. up against a service provided by a GYN office 99397 dx V72.31 routine gyn service??. I billed a 99397 with dx V70.0 and it is denying as max met due to a GYN exam that pt had at another office....and the GYN office billed it as 99397 dx V72.31. Thank you.

  2. Default
    Are you billing PCP Services? If Yes, you should contact UHC and explain that PCP services are different from GYN and therefore Dx Codes are v70.0 and v72.31. Ask them to reprocess. Hope this helps.

  3. #3
    Chesapeake, Virginia
    Patients are only allowed to have 99397 billed once per year, hence the denial for max met. This is a comprehensive physical exam, I'd question the appropriateness of this being billed by the GYN.

  4. Default
    It is most appropriate to charge code sets 99381-99397 for annual well women/pap/breast exam done by an OB/GYN. Per CPT "The "comprehensive"nature of the preventive medicine services codes 99381-99397 reflects an age and gender appropriate history/exam and is [B]not [B]synonymous with the "comprehensive " examination required in Evaluation and Management codes 99201-99350. All my non Medicare pt that come in for annual breast/pelvic exam with or w/o pap are coded to 99381 code set or 99391 code set with out issue from the insurance carriers.

  5. #5
    Tacoma, WA
    This is an unfortunately problem I have run into for years. The insurances that limit clients to one annual physical per year do not take into account that many women have a routine annual pap/pelvic exam with their gynecologist and then see the PCP for their comprehensive physical exam. The CPT codes are the same for both providers, just the diagnosis codes are different. This will also come up if there is a dollar limit on preventive medicine per year.

    I worked in OB/GYN for many years and this issue would come up every year. I tried to educate patients to look into their benefits before their visit so they would be aware whether or not it would be covered. Sometimes they would just have the PCP do the pap/pelvic/breast exam as part of their annual physical. Or sometimes they would alternate years with which provider they visited. Hopefully with healthcare reform more preventive services will be covered and this problem will become a thing of the past!!

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