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Screening Pelvic Examinations Medicare Claims Processing Manual Chapter 18 §40 (Rev. 1, 10-01-03) B3-4603.2, A3-3, 3628.1B §4102 of the Balanced Budget Act of 1997 provides for coverage of screening pelvic examinations (including a clinical breast examination) for all female beneficiaries, subject to certain frequency and other limitations. A screening pelvic examination (including a clinical breast examination) should include at least seven (7) of the following eleven (11) elements: • Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge • Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses Pelvic examination (with or without specimen collection for smears and cultures) including: • External genitalia (for example, general appearance, hair distribution, or lesions) • Urethral meatus (for example, size, location, lesions, or prolapse) • Urethra (for example, masses, tenderness, or scarring) • Bladder (for example, fullness, masses, or tenderness) • Vagina (for example, general appearance, estrogen effect, discharge lesions, pelvic support, cystocele, or rectocele) • Cervix (for example, general appearance, lesions, or discharge) • Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support) • Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity) • Anus and perineum Coding for Screening Pelvic Examinations Medicare Claims Processing Manual Chapter 18 §40.2 (Rev. 1, 10-01-03) B3-4603.2.B and C, A3- 3628.1.B.1 A HCPCS code has been established for the pelvic and clinical breast examinations. Use code G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination). Coding for Obtaining the Pap smear Medicare Claims Processing Manual Chapter 18 §30.5.D (Rev. 795, Issued: 12-30-05; Effective: 10-01- 04; Implementation: 04-03-06) Use HCPCS code Q0091 to report the obtaining a screening pap smear during an encounter. This code is subject to the same frequencies and diagnoses as pelvic and clinical breast exam. Payment for Q0091 is paid under the Medicare physician fee schedule. Deductible is not applicable, however the coinsurance applies. Effective for services on and after July 1, 2005, on those occasions when physicians must perform a screening Pap smear (Q0091) that they know will not be covered by Medicare because the low risk patient has already received a covered Pap smear (Q0091) in the past 2 years, the physician can bill Q0091 and the claim will be denied appropriately. The physician shall obtain an advance beneficiary notice (ABN) in these situations as the denial will be considered a not reasonable and necessary denial. The physician indicates on the claim that an ABN has been obtained by using the GA modifier. Effective for services on or after April 1, 1999, a covered evaluation and management (E/M) visit and code Q0091 may be reported by the same physician for the same date of service if the E/M visit is for a separately identifiable service. In this case, the modifier “-25” must be reported with the E/M service and 5-44 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
the medical records must clearly document the E/M reported. Both procedure codes should be shown as separate line items on the claim. These services can also be performed separately on separate office visits. Repeat Obtaining Screening Pap Smear Due To Inadequate Specimen Related Change Request (CR) #: 3659 Medlearn Matters Number: MM3659 Related CR Transmittal #: 440 Implementation Date: July 5, 2005 When a Pap smear specimen is not sufficient for the laboratory to interpret the results and another specimen is needed report Q0091 and append the -76 modifier to indicate it is a repeat specimen. The Carrier will pay for the collection of the specimen. Physicians should not report the screening pelvic examination again as the entire service is not medically necessary. It is also inappropriate to report an E/M code unless the patient has another problem needing a medically necessary evaluation on the same date of service. CMS Incident To Clarification CMS Region V clarified that screening pelvic examination with clinical breast exam (G0101) and obtaining screening Pap smear (Q0091) cannot be billed “incident to” the physician’s services. The physician or nonphysician practitioner who PERFORMS the service(s) must report these screening services. This clarification applies to all screening services. Covered Diagnoses For Reporting Screening Pelvic Examination Or The Obtaining Of A Screening Pap Smear Medicare Claims Processing Manual Chapter 18 §30.6 (Rev. 1, 10-01-03) AB-03-054 (CR 2637) (Rev. 440, Issued: 01-21-05, Effective: 07-01-05, Implementation: 07-05-05) Applicable Diagnoses for Billing a Carrier There are a number of appropriate diagnosis codes that can be used in billing for screening Pap smear services that the provider can list on the claim to give a true picture of the patient’s condition. To be covered one of the following diagnoses must be listed in Item 21 of Form CMS-1500 or the electronic equivalent. Below are the current diagnoses that should be used when billing for screening Pap smear services. Effective, July 1, 2005, V72.31 is being added to the CWF edit as an additional low risk diagnosis. The following chart lists the diagnosis codes that CWF must recognize for low risk or high-risk patients for screening Pap smear services. Low Risk Definitions Diagnosis Codes V76.2 Special screening for malignant neoplasms, cervix V76.47 Special screening for malignant neoplasm, vagina V76.49 Special screening for malignant neoplasm, other sites NOTE: providers use this diagnosis for women without a cervix. V72.31 Routine gynecological examination NOTE: This diagnosis should only be used when the provider performs a full gynecological examination. High Risk Diagnosis Code V15.89 Other If one of these diagnoses is not present or if the frequency requirements are not met, the CWF will reject the claim as “not medically necessary.” 5-45 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43: HOME SERVICES - CPT CODES 99341-993

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