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Medicare Breast exam without pap or pelvic exam

  1. Question Medicare Breast exam without pap or pelvic exam
    Medical Coding Books
    How would you bill Medicare for a patient scheduled for her annual gyn exam w/ pap, but elects only for a full H&P w/ breast exam Thanks!

  2. #2
    Location
    Evansville Indiana
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    451
    Default breast exam
    Breast exam is included in the E&M.
    LeeAnn

  3. Default
    I have never tried this before with Medicare, but their is a HCPCS code S0613. Would we not just carve that out from the E/M?

    Robin King, CPC

  4. Default The E&M...
    Quote Originally Posted by cheermom68 View Post
    Breast exam is included in the E&M.
    LeeAnn
    Are you referring to the 99211-99214's or the G0101 w/ 99-GA-52?

  5. #5
    Location
    Evansville Indiana
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    451
    Default Breast exam
    When only a breast exam is performed with no other parts of the pelvic exam it would be included in the office visit 992**. In my experience Medicare will not pay the S codes, those are generally Anthem codes. The G0101 requires 7 elements of the pelvic exam, I would not consider doing one of them enough to bill the G0101 with a 52 modifier. (in my opinion)

  6. Smile Thanks!
    Thanks..., and Happy Holidays!!

  7. #7
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by Choughton View Post
    How would you bill Medicare for a patient scheduled for her annual gyn exam w/ pap, but elects only for a full H&P w/ breast exam Thanks!
    So did the patient elect not to have a pelvic exam either? If she had a complete routine physical exam but declined the pelvic exam, you just bill a preventive medicine E/M the breast exam is included and it will not be covered by Medicare, unless she was having the new wellness exam that is allowed by Medicare. But those exams only cover very specific screenings, not complete physicial exams.

    If she did have a pelvic and breast exam, just no pap test then you can bill the G0101 code with a GA modifier (as long as she signed the ABN) and carve that out of the preventive E/M code for the complete physical exam.

    All depends on what was documented.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  8. Default
    Thank you;-)

  9. Default
    Thanks Arlene. Good to know for the future.


    Robin King, CPC

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