Well-Woman Exam Claims Squeaky-Clean

To code a well-woman exam correctly, you’ve got to know two key concepts: how Medicare and private-payer guidelines differ, and when you should separately code breast/pelvic exams and Pap smears.

Best bet: Use these two quick tips for accurate well-woman coding.

1. Break Out Services for Medicare:
If the family physician provides a complete well-woman exam for a Medicare patient, you should report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the breast and pelvic exams. When the physician also obtains a Pap smear, use Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania.

If these are done as part of an annual preventive medicine visit, the physician should also code the appropriate preventive medicine service code (e.g., 99397, Periodic comprehensive preventive medicine reevaluation and management of an individual …; 65 years and over).

If these are done in conjunction with a problem-oriented visit, you can report a new or established patient E/M code (99201-99215) in addition to G0101 and Q0091, Pohlig says.

But the FP must have documented a separate and distinct E/M service, and you must attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code. For example, the physician performs the well-woman exam but also evaluates and manages the patient’s ongoing dysfunctional uterine bleeding.

Important: For Medicare patients at normal risk, you can report a Pap smear only once every two years. The diagnoses your physician will use in these cases include V72.31 (Routine gynecological examination), V76.2 (Special screening for malignant neoplasms; cervix) and V76.47 (… other sites; vagina), says Pat Larabee, CPC, CCP, a coding specialist at InterMed, a multispecialty healthcare network in South Portland, Maine.

High-Risk Coding:

If the patient is high-risk, you can bill the Pap smears annually. To classify a patient as high-risk, you will likely use V15.89 (Other specified personal history presenting hazards to health; other) for medical justification of a screening Pap smear, Larabee says.

“Medicare has specific requirements that have to be met for a patient to be considered high-risk,” Larabee adds. For this reason, your physician should supply secondary diagnoses to explain why the patient is high-risk. These diagnoses include:

– History of HIV (V08 or 042)

– History of sexually transmitted diseases (V13.8)

– Five or more sexual partners (V69.2)

– Began sexual activity before 16 years of age (V69.2)

– Diethylstilbestrol (DES) exposure (760.76)

– Seven years without a Pap smear (V15.89)

– Absence of three consecutive negative Pap results (795.0x).

2. Rely on CPT Codes for Private Insurers

Although most commercial payers follow Medicare’s lead when setting coding policies, many accept neither G0101 nor Q0091 for well-woman visits. In those cases, you may report one of CPT’s preventive-medicine codes (99381-99397), depending on your payers’ policies, Pohlig says.

Coding tip: The correct preventive-medicine code depends on whether the patient is new or established, and the patient’s age. For instance, if your FP sees a new patient, you’ll likely report one of three codes:

– 99385–Initial comprehensive preventive medicine evaluation and management of an individual including an age-and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; 18-39 years

– 99386–… 40-64 years

– 99387–… 65 years and over.

If the patient is established, you should report one of these codes:

– 99395–Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age-and gender-appropriate history, examination … established patient; 18-39 years

– 99396–… 40-64 years

– 99397–… 65 years and over.

In some cases, private payers will reimburse you for handling the Pap specimen. If so, you can also report 99000 (Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory). Typically, you’ll link ICD-9 code V76.47 to 99000.

Important: You should use 99000 if the physician incurs a cost for handling the specimen or to reflect the work involved in the preparation of a specimen before sending it to the laboratory

View all Articles by: Melissa Clark, CCS-P