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Medicare G code

  1. #1
    Moore Oklahoma
    Question Medicare G code
    Medical Coding Books
    I have a denial from medicare, stating that I need a G code, services provided were general physical examination with breast and rectal exam, no pap or GU exam was performed....Would G0101 be appropriate even if the GU exam was not performed? And would I still use the V70.0 Dx? Any assistance would be greatly appreciated.
    Last edited by mlbaker1974; 09-23-2008 at 12:03 PM.

  2. #2
    Default Denial
    What CPT and ICD-9 code did you bill?
    Heather Winters, CPC, CFPC

  3. #3
    Moore Oklahoma
    99397 with dx V70.0, V76.19,v10.3,V76.41

  4. #4
    Default Medicare Preventive Services
    Medicare does not normally pay for preventive services 99397. Digital Rectal Examinations are covered for male patients for prostate screening, however, they are not covered for female patients. If an occult stool test was done, you can bill that with a G code and the V76.41. You can check on preventive services coverage at the following link.
    Heather Winters, CPC, CFPC

  5. #5
    Moore Oklahoma
    Thank you

  6. #6
    Omaha, Nebraska
    Default G0101 plus 99397
    Is it appropriate to bill G0101 WITH 99397? I'm thinking it is - but, my mom is questioning a bill from her physician. To my knowledge, there is nothing illegal or fraudulent with un-bundling services is there?


  7. #7
    St.Petersburg, Fl
    also there is a GY that goes in front of the level of servie for medicare only...keep in mind if its a pap a 25 modifer applies to the level of service. This is only for medicare patients.
    Alecia Peck CPC

  8. #8
    Greeley, Colorado
    Quote Originally Posted by ckkohler View Post
    Is it appropriate to bill G0101 WITH 99397? I'm thinking it is - but, my mom is questioning a bill from her physician. To my knowledge, there is nothing illegal or fraudulent with un-bundling services is there?

    If the doctor did a pelvic and breast exam s/he can bill G0101 with 99397. The fee for G0101 must be deducted from the fee for 99397, so your mom's bill for 99397 should be a little less than her doctor's normal fee. If they did not reduce 99397 by the amount billed for G0101 she needs to call the billing dept and get that worked out.
    Lisa Bledsoe, CPC, CPMA

  9. Post G0101
    Medicare clarified recently that in order to bill the G0101 you must do the breast exam (which it sounds like was done) and a total of 7 of the 11 exam elements defined by G0101. So, it doesn't sound like you can bill that code.

    It is appropriate to bill a 99397 and a G0101 to a Medicare patient, and the Q0091 (obtaining the pap smear) when all were performed. Of course, Medicare will pay on the G and Q codes, but the patient pays the difference between the fee for the 99397 and the fee for the covered Medicare services.

    If your provider also addressed medical problems, and these are clearly documented, you can bill Medicare for an office visit, as well, and subtract the fee for that from the 99397.
    Betsy Nicoletti, M.S., CPC

  10. #10
    North Carolina

    Your name rings a bell with me. Have you conducted an E/M Seminar on Physician Pearls?
    Rebecca CPC, CPMA, CEMC

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