billing G0101, q0091 (pap smear) procedure code with covered DX

Medicare

Q0091 is a code developed by Medicare for services provided to Medicare patients. Medicare does not reimburse for comprehensive preventive services, such as those reported with CPT-4 codes 99384 – 99397. Medicare allows payment of code Q0091 as an exception to its general rule since there would otherwise be no reimbursement for the collection service.

Providers should report code Q0091 to Medicare for the collection of screening pap smears for Medicare patients.


However, collection of a diagnostic pap smear for a Medicare patient (performed due to illness, disease, or symptoms indicating a medically necessary reason) is included in the physical examination portion of a problem-oriented E/M service and is not reported or reimbursed separately.

DIAGNOSTIC CODING FOR THE COLLECTION OF PAP SMEAR AND SCREENING PELVIC EXAM

Both the collection of the screening Pap smear specimen (Q0091) and screening pelvic exam (G0101) are reported with one of the following diagnosis codes:

• V72.31 – routine gynecological exam (reported when provider performs a full gyn examination)

• V76.2 - Special screening for malignant neoplasms, cervix (patient has a cervix)

• V76.47 - Special screening for malignant neoplasms, vagina (patient does not have a cervix)

• V76.49 - Special screening for malignant neoplasms, other sites

• V15.89 - Other specified personal history presenting hazards to health. (patient is considered high risk according to Medicare’s criteria)

Collection of a diagnostic Pap smear (performed due to illness, disease, or symptoms indicating a medically necessary reason) is included in the physical examination portion of a problem-oriented E/M service and is not reported or reimbursed separately.

Often, both the G0101 and Q0091 are provided during the same visit. An example follows.

Example 1: Collection of a screening Pap smear (Q0091) reported with the screening pelvic  examination (G0101):


Bill to: HCPCS Codes         ICD-9 Codes Charge
Medicare G0101-GA V76.2, V76.47, V76.49, or V15.89 $34.60
Q0091-GA V76.2, V76.47, V76.49, or V15.89 $40.00




Patient N/A N/A $0.00
Total amount billed $74.60

The assumption is that the physician in this example provided only Medicare covered services with no additional preventive care.

The GA modifier indicates that an ABN has been signed. Note that the charges listed in the example above are Medicare allowable amounts but do not include the geographical adjustment factor.
The patient is not initially billed for either of these services since Medicare covers them. Once Medicare has processed the claim, the physician bills the patient for her portion (20% of the Medicare approved amount).

Screening Papanicolaou Smear— HCPCS code Q0091

Insurance considers the collection of the pap specimen to be included in the E&M code when services are provided for a gynecological (GYN) exam (Procedure  codes 99381 through 99397).

• When Q0091 is billed alone with a diagnosis for a GYN exam; the service will be processed as an annual GYN exam.

• If Q0091 is billed in conjunction with an E&M code for the GYN exam, Q0091 will be processed as provider write-off. Allowance for the handling of the specimen using Procedure  99000 will be denied as bundled when billed in conjunction with the GYN exam.

• We will consider Q0091 for payment, if billed with an E&M code using a diagnosis other than the GYN exam if modifier -25 is used with the E&M code. Diagnosis and chart notes must support use of the E&M code in conjunction with Q0091.


• If Q0091 is billed with an E&M code without modifier -25, Q0091 will not be approved and will be processed as provider write-off.

Q: Why is Q0091 not separately reimbursable when billed with a Preventive Medicine code?

A: UnitedHealthcare Community Plan considers Q0091 (obtaining, preparing and conveying a cervical or vaginal smear to the laboratory) to be an integral part of a Preventive Health Care service. Therefore, this component of a Preventive visit is not separately reimbursable.



G0101, G0102, Q0091

Prolonged Services Codes

0403T, 99354, 99355, 99415, 99416, G0296

Counseling Services Codes

0403T, 99401, 99402, 99403, 99404, 99406, 99407, 99408, 99409, 99411, 99412, 99415,99416, G0296 G0396, G0397, H0005, S0257, S0265, S9470, T1006, T1027

Medical Nutrition Therapy Services Codes

97802, 97803, 97804, G0270, G0271

Visual Function

99172


Preventive Medicine with Screening Services

The preventive medicine E/M service incorporates age and gender appropriate services. Therefore, when a preventive medicine E/M code and one of the following screening services codes (96110, G0101, G0102, G0442, G0444, Q0091) are submitted for the same patient by the same physician or other health care professional on the same date of service, only the preventive medicine code is reimbursed.

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