- Early onset of sexual activity (under age 16)
- Multiple sexual partners (five or more in a lifetime)
- History of a sexually transmitted disease (including HIV infection)
- Fewer than three negative Pap smears within the previous 7 years
- Diethylstilbestrol (DES)-exposed daughters of women who took DES during pregnancy.
If the Medicare-eligible patient is still of childbearing age, she is also considered high-risk if she has had an examination that indicated the presence of cervical or vaginal cancer or other genital abnormalities during any of the preceding 3 years. Note that these criteria do not include a history of breast cancer or a past history of cancer more than 3 years ago.
Billing. Because Medicare is paying only for a portion of the preventive service, you will need to subtract the Medicare allowable for codes G0101 and Q0091 from your normal fee for the preventive service.
- Example: If your usual fee for 99397 is $200, and the Medicare allowable for both the G and Q service is $82, you will charge the patient for the noncovered parts of the service at the rate of $118, and you will bill Medicare for their share of $82. You will collect from all sources the $200 for the preventive service. Remember, however, to get the patient to sign an ABN with regard to the Medicare part of the service. This will ensure that, if denied by Medicare, the patient will be held fully responsible for the denied amount.
The Medicare modifier is –GA (add it to codes G0101 and Q0091). Diagnostic coding is V72.31 (because a pelvic exam is performed). This code may also be linked to the collection code. For a high-risk patient, use code V15.89 (rather than V72.31). This code must be linked to the G and Q codes.
"Guide to Billing the Medicare Annual Exam" is a detailed Medicare checklist offered by the author that includes all billing scenarios for a Medicare patient. Click here to download a PDF.
Ms. Witt can be contacted directly at nielynco@aol.com should you have additional questions regarding coding and billing for preventive services.
Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American Congress of Obstetricians and Gynecologists.
ON THE WEB
A special downloadable handout including all Medicare billing scenarios, at obgmanagement.com
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