An Overview of Medicare Billing for Well Woman Exam

by | Published on Sep 28, 2015 | Healthcare News

Medicare Billing
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Women under age 65 can schedule a Well Woman Visit each year to maintain health and prevent disease. A Well Woman Visit includes a complete checkup, and is separate from any other visit made to the practitioner for sickness or injury. The Affordable Care Act entitles all women to one free well-woman checkup every year. The cost is covered by most insurance companies.

Designed to ensure preventive care for women, these visits include the following:

  • Screenings or medical tests to check for diseases early when it is easier to treat them.
  • Services such as shots that can ensure better health and prevent health issues.
  • Education that will enable the patient to make correct health decisions.

A physical examination is a key component of an annual Well Woman Visit and the components of this exam may vary in keeping with the patient’s age, physician preference, and risk factors. Medicare covers certain well woman exam screenings every two years or annually. If you know the right codes, you can correctly bill for the care provided at a well-woman visit to ensure efficient medical billing and obtain reimbursement quickly.

Annual Wellness Visit and Well-Woman Visit

Medicare’s Annual Wellness Visit (AWV), (which includes screening for disease, assessing the risk of future health problems, providing guidance for a healthy lifestyle and updating vaccinations) provides Personalized Prevention Plan Services (PPPS) for beneficiaries who have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months, and those who are not within the first 12 months of their first Medicare Part B coverage period. AWV is to be reported initially using G0438, and all subsequent encounters using G0439. AWV does not relate to the annual well woman exam, which is a totally separate E/M service from AWV. Annual wellness visit is covered once every 12 months; 11 full months must have passed since the last visit.

How to bill out for an annual Well Woman Exam for a patient covered by Medicare? Unless you specifically evaluate a patient for both the AWV and a Well Woman Exam, do not bill out the AWV. A primary care physician providing the annual exam will also include the pelvic and breast exam and a pap smear collection. However, if the patient wants the well woman exam to be performed by her gynecologist, the PCP has to document the deferment of the pelvic and breast exams and pap smear collection by the patient, and note that these will be performed by her gynecologist.

  • Take the case of a patient who comes in for an annual exam and the Well Woman Exam components are not done during the visit. If the provider sees the patient again during a second visit so that a comprehensive exam can be made, this second visit is not billable since it is considered a continuation of the first.
  • Take the case of a patient who did not want the pelvic/breast exam and pap smear collection to be done during the routine physical and wanted to see a gynecologist for the same. Suppose this patient comes back later for these screenings having decided not to see the gynecologist, you cannot bill for these separately since they are already included in the annual.

Covered Services and Their Coding

Medicare provides coverage for pelvic and clinical breast examination, pap smear and fecal occult blood test. You should use the appropriate procedure code (HCPCS code) and diagnosis code (ICD-9) for claiming reimbursement. If high risk factors are found in beneficiaries, Medicare will pay for certain screening tests annually. The corresponding high risk diagnosis code should be reported in such cases. Here is how to code for each service.

Pelvic and Breast Examination

  • G0101: Cervical or vaginal cancer screening; pelvic and clinical breast examination

ICD-9 Codes

Report any of the following codes depending upon the patient.

Low Risk

  • V72.31: Routine gynecological exam
  • V76.2: Special screening for malignant neoplasms, cervix
  • V76.47: Special screening for malignant neoplasms, vagina
  • V76.49: Special screening for malignant neoplasms, other sites

High Risk

  • V15.89: Other specified personal history presenting hazards to health

Medicare covers this service once in two years and if the patient is considered high risk, G0101 is reimbursed on an annual basis. To ensure proper reimbursement, you must document at least 7 of the 11 elements given below:

  • 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
  • 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

Screening Pap Test

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

ICD-9 Codes

Low Risk

  • V72.31: Routine gynecological exam
  • V76.2: Special screening for malignant neoplasms, cervix
  • V76.47: Special screening for malignant neoplasms, vagina
  • V76.49: Special screening for malignant neoplasms, other sites

High Risk

  • V15.89: Other specified personal history presenting hazards to health

Like G0101, Q0091 is also reimbursed every two years or on an annual basis, if high risk factors are found.

Fecal Occult Blood Test

  • 82270: Fecal Occult Blood Test

ICD-9 Code

As per the CMS, the appropriate code may vary according to the carrier. An applicable code is given as follows.

  • V76.51: Special Screening for Malignant Neoplasms; Colon

Fecal occult blood test can be billed annually for Medicare.

Modifiers for ABN

Providers are required to give Medicare beneficiaries a Medicare Waiver Liability known as Advanced Beneficiary Notice (ABN) for the services that may not be covered or considered medically necessary. ABNs are not applicable for services that exclude Medicare coverage. A complete and signed ABN is crucial for ensuring reimbursement for your services as it will notify Medicare that the patient acknowledges that certain procedures are performed and the patient will be personally responsible for complete payment if Medicare rejects the claim for a particular procedure. It is not possible to bill your patient if there is no signed ABN and the claim must be written off, if denied by Medicare. The general criteria for ABN are as follows:

  • The patient’s name, specific service and estimated charge amount must be included in the ABN
  • The ABN must be given to the patient before providing any service or procedure
  • An ABN cannot be given if the patient is under duress or needs emergency treatment

When you are billing for a service with ABN, you must add any of the following modifiers appropriately.

  • GA Modifier:Waiver of Liability Statement Issued as Required by Payer Policy (report this modifier to indicate an ABN is on file, which allows the provider to bill the patient if not covered by Medicare)
  • GX Modifier: Notice of Liability Issued, Voluntary Under Payer Policy (use this modifier only to specify a voluntary ABN was issued for services that are not covered)
  • GY Modifier: Notice of Liability Not Issued, Not Required Under Payer Policy (report this modifier to notify Medicare that you know this particular service or procedure is excluded so as to obtain a denial on a non-covered service)
  • GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary (Apply this modifier in case of a situation when an ABN may be required, but was not obtained)

Since Medicare billing policies change constantly, check with the latest updates frequently before billing your patient. Relying upon professional medical billing and coding services can reduce the time and effort you invest in this job and help you to focus more on providing quality care.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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