In order to report a well-woman exam correctly, you need to be aware of two important concepts: How Medicare and private payers' guidelines differ, and when you should code breast/pelvic exams and Pap smears separately.
Want to know more about well-woman coding? Take a look at these quick tips:
Break out services for Medicare
First, if the ob-gyn provides a complete well-woman exam for a Medicare patient, you should use G0101 for the breast and pelvic exams, and bill the patient for the non-covered part of the exam using 99387 or 99397.
When the doctor also gets hold of a Pap smear, use Q0091. Bear in mind that you can also report a new or established patient evaluation & management code (99201-99215) apart from G0101 and Q0091 if the doctor addresses significant problems at the time of the well-woman visit.
However the doctor must have documented a separate and distinct evaluation & management service and you must add modifier 25 to the evaluation & management code. For instance the doctor carries out the well-woman exam but also evaluates and manages the patient's ongoing dysfunctional uterine bleeding.
Remember that for Medicare patients at normal risk, you can report a Pap smear once every two years. The diagnoses your doctor will use in these instances include V72.31, V76.2, V76.47 or V76.49.
And when your coding system changes in year 2013, you will report the following equivalents: V72.31 = ZØ1.411, V76.2 = Z12.4, V76.47 = Z12.72 and V76.49 = Z12.89.
Stay away from high-risk coding
Want to know more about well-woman coding? Take a look at these quick tips:
Break out services for Medicare
First, if the ob-gyn provides a complete well-woman exam for a Medicare patient, you should use G0101 for the breast and pelvic exams, and bill the patient for the non-covered part of the exam using 99387 or 99397.
When the doctor also gets hold of a Pap smear, use Q0091. Bear in mind that you can also report a new or established patient evaluation & management code (99201-99215) apart from G0101 and Q0091 if the doctor addresses significant problems at the time of the well-woman visit.
However the doctor must have documented a separate and distinct evaluation & management service and you must add modifier 25 to the evaluation & management code. For instance the doctor carries out the well-woman exam but also evaluates and manages the patient's ongoing dysfunctional uterine bleeding.
Remember that for Medicare patients at normal risk, you can report a Pap smear once every two years. The diagnoses your doctor will use in these instances include V72.31, V76.2, V76.47 or V76.49.
And when your coding system changes in year 2013, you will report the following equivalents: V72.31 = ZØ1.411, V76.2 = Z12.4, V76.47 = Z12.72 and V76.49 = Z12.89.
Stay away from high-risk coding
You can bill the Pap smears annually if the patient is high-risk. In order to classify a patient has high-risk, you will have to report V15.89 for medical justification of a screening Pap smear.
Secondly, you should rely on CPT codes for private insurers
Even though most commercial payers follow Medicare's lead when setting coding policies, many accept neither G0101 nor Q0091 for well-woman visits. This is owing to the fact that Medicare codes only include a physical examination however don't cover history or counseling. In those instances, you may use one of CPT's preventive-medicine codes (99381- 99397), as per your payer's policies.
Tip: The right preventive-medicine code depends on whether the patient is new or established, and the patient's age.
Secondly, you should rely on CPT codes for private insurers
Even though most commercial payers follow Medicare's lead when setting coding policies, many accept neither G0101 nor Q0091 for well-woman visits. This is owing to the fact that Medicare codes only include a physical examination however don't cover history or counseling. In those instances, you may use one of CPT's preventive-medicine codes (99381- 99397), as per your payer's policies.
Tip: The right preventive-medicine code depends on whether the patient is new or established, and the patient's age.
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