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

Procedure code and Descripiton

Q0091  Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory


G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination)



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.


Screening Papanicolaou Smear Q0091 Cervical or vaginal cancer screening; pelvic and clinical breast examination G0101

A Screening Pap Smear (HCPCS code Q0091) and/or the Cervical or Vaginal Cancer Screening (G0101) is considered part of a preventive or problem based office visit and is not separately reimbursable. As of February 21, 2011, the screening services of Q0091 and/or G0101 are considered for separate reimbursement when reported in addition to a significant and separately identifiable E/M service. Modifier 25 must be appended to the E/M service for the screening services to be separately reimbursed. Documentation supporting the unrelated E/M service meeting the Modifier 25 requirements must be maintained and made available to us upon request. Exception: Q0091 and G0101 will remain a component of a Preventive Medicine E/M Service and will not be separately reimbursed. Modifier 25 appended to the Preventive Medicine E/M CPT Codes will not override the edit (Preventive Medicine E/M CPT codes 99381- 99397).

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.


Screening Pap tests and pelvic examinations are important parts of preventive health care for adult women:

¦ A screening Pap test (also called a Pap smear) is a laboratory test that consists of a routine exfoliative cytology test (Papanicolaou test) for early detection of cervical cancer. It includes collection of a sample of cervical cells and a physician’s interpretation of the test results.

¦ A screening pelvic examination helps detect pre-cancers, genital cancers, infections, sexually transmitted infections (STIs), reproductive system abnormalities, and other genital and vaginal problems. For more information on what is included in a screening pelvic examination, refer to the “Medicare National Coverage Determinations Manual,” Publication 100-03, Chapter 1, Part 4, Section 210.2 on the Centers for Medicare & Medicaid Services (CMS) website. This booklet can help you talk with your beneficiaries about Medicare-covered screening Pap tests and pelvic examinations. It can also help you correctly bill for these services.

HCPCS Code Code Descriptor

Q0091 Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory NOTE: Another specimen may be collected in situations where unsatisfactory screening Pap smear specimens have been collected and conveyed to clinical laboratories that are unable to interpret the test results. To bill for this reconveyance, annotate the claim with HCPCS code Q0091 along with modifier -76 (repeat procedure or service by same physician or other qualified health care professional).

Q0091  Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

NOTE: In those situations where unsatisfactory screening Pap smear specimens have been collected and conveyed to clinical laboratories unable to interpret the test results, another specimen may be collected.  To bill for this reconveyance, annotate the claim with HCPCS code Q0091 along with modifier -76 (repeat procedure or service by same physician or other qualified health care professional).


Guideline from UHC

As, there are often no symptoms of cervical dysplasia until the disease has progressed into advanced cancer, it is crucial that sexually active women, or women over age 20, have yearly Pap smears. In addition, women who experience bleeding between menstrual periods, bleeding after intercourse, abnormal vaginal discharge, abdominal pain or swelling, urinary symptoms, or pelvic pain should be evaluated by a healthcare provider, even if it is not the regular time for a Pap test.

In countries where women do not have access to routine Pap tests, cervical cancer is much more common. In fact, cervical cancer is the major cause of cancer deaths in women in many developing countries and these cases are usually diagnosed at a late (invasive) stage, rather than as pre-cancers or early cancers

Risk Factors

There are multiple risk factors that predispose women to developing cervical cancer. These risk factors include infection with Human Papillomavirus (HPV), smoking, immunosuppression, Chlamydia infection, diet, oral contraceptives, multiple full-term pregnancies, young age at the first full-term pregnancy, poverty, diethylstilbestrol (DES), and a family history of cervical cancer.1 HPV, a sexually transmitted infection, has been strongly linked to cervical cancer. It has been stated that the demonstration that cervical cancer is caused by the persistent infection by certain genotypes of HPV is one of the most important discoveries in the investigation of cancer etiology over the past 25 years.6

This monumental discovery led to the development of two HPV vaccines that are currently on the market, Gardasil (quadrivalent) and Cervarix (bivalent). Both vaccines protect against the two HPV types (HPV-16 and HPV-18) that cause 70% of cervical cancers, 80% of anal cancers, 60% of vaginal cancers, 40% of vulvar cancers as well as most HPV induced oral cancers. Gardasil also protects against the two HPV types (HPV-6 and HPV-11) that cause the vast majority of genital warts (90%). The Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetrics and Gynecology (ACOG) recommend that bivalent or quadrivalent HPV vaccination be routinely offered to girls between the ages of 11 and 12 years (as young as 9 years) to prevent cervical dysplasia and cervical cancer. In addition, catch-up vaccination is recommended for women aged 13 to 26 years who have not been previously vaccinated. Given that these vaccines only cover some high-risk types of HPV, women should continue with regular Pap smear screening after vaccination.

A task force appointed by the Society of Gynecologic Oncology (SGO) and the American Society of Colposcopy and Cervical Pathology (ASCCP) have prepared an interim clinical guidance document for HPV primary screening in the United States.

The Pap Test and Other Conditions

While a Pap test does not test for the majority of sexually transmitted diseases (STDs), it may occasionally show signs of infection. Certain types of Pap smear may include HPV testing on the sample that is taken from your cervix, and it is also possible that swelling or damage from other STDs could show up on your Pap smear

Additionally, sometimes a “wet mount” is performed in conjunction with or separate from a Pap test. A wet mount is a slide made from a swab of your vagina that looks for vaginal infections and other conditions that can easily be identified visually such as Bacterial vaginosis (BV) and trichomoniasis. There are many gynecological Issues in women who are human immunodeficiency virus positive (HIV+). HIV+ women are more likely to be infected with HPV than HIV-negative women and HIV+ women are 10 times more likely to have abnormal Pap smears than HIV negative women.8 In addition, HIV+ women, especially women with advanced HIV disease, are also more likely to develop dysplasia (abnormal cervical cells) as a result of HPV.8

The Centers for Disease Control (CDC) recommends that :

* HIV+ women have a complete gynecological examination, including a Pap smear, when they are first diagnosed and when they first seek prenatal care

* HIV+ women have another Pap six months later

* If both tests are normal (negative), yearly screening is recommended

* Women who have had dysplasia should receive a Pap smear more often and may return to getting annual Pap smears if they have had two normal exams in a row Leiomyomas, also known as fibroids, are common benign tumors of the uterine corpus but may also appear in the cervix.9 Whenever an asymptomatic cervical fibroid is discovered; the possibility of cervical cancer should be ruled out.


Screening Pap tests and pelvic examinations are important parts of preventive health care for adult women:

¦ A screening Pap test (also called a Pap smear) is a laboratory test that consists of a routine exfoliative cytology test (Papanicolaou test) for early detection of cervical cancer. It includes collection of a sample of cervical cells and a physician’s interpretation of the test results.

¦ A screening pelvic examination helps detect pre-cancers, genital cancers, infections, sexually transmitted infections (STIs), reproductive system abnormalities, and other genital and vaginal problems. For more information on what is included in a screening pelvic examination, refer to the “Medicare National Coverage Determinations Manual,” Publication 100-03, Chapter 1, Part 4, Section 210.2 on the Centers for Medicare & Medicaid Services (CMS) website. This booklet can help you talk with your beneficiaries about Medicare-covered screening Pap tests and pelvic examinations. It can also help you correctly bill for these services.

HCPCS Code Code Descriptor

Q0091 Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory NOTE: Another specimen may be collected in situations where unsatisfactory screening Pap smear specimens have been collected and conveyed to clinical laboratories that are unable to interpret the test results. To bill for this reconveyance, annotate the claim with HCPCS code Q0091 along with modifier -76 (repeat procedure or service by same physician or other qualified health care professional).

No comments:

Top Medicare billing tips