Physicians Coding Strategist:
Tips for coding new Medicare benefits
Coverage has expanded
Medicare has expanded coverage for several preventive health services in recent months, including the following:
• Colonoscopies. In July, Medicare started covering screening colonoscopies every 10 years for beneficiaries not considered at high risk for colorectal cancer, provided they had not already had a screening flexible sigmoidoscopy within the last 48 months. Medicare also covers a screening colonoscopy for high-risk beneficiaries every two years. High-risk individuals are defined as those with a family history of colorectal cancer, prior experience with cancer or precursor neoplastic polyps, a history of chronic digestive disease conditions (including inflammatory bowel disease, Crohn’s disease, or ulcerative colitis), the presence of any appropriate recognized gene markers for colorectal cancer, or other predisposing factors.
According to Brett Baker, a third-party payment specialist with the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) in Philadelphia, if you want to bill for a screening colonoscopy for a beneficiary who is not considered high risk for colorectal cancer, you must use HCFA Common Procedure Coding System (HCPCS) code G0121. The code applies to colorectal cancer screening for individuals who do not meet the criteria for high risk.
The 2001 Medicare payment for a screening colonoscopy performed in a hospital or other facility on a patient who is not high risk for colorectal cancer (G0121) is $239.51. (This rate will vary slightly by geographic area.) Medicare gives the same payment for a screening colonoscopy on a high-risk beneficiary, G0105, and for a diagnostic colonoscopy, CPT 45378.
Coding Pap smears/pelvic exams
• Pap smears/pelvic exams. In July, Medicare began paying for screening Pap smears and pelvic exams, which include clinical breast exams, every two years for women who are postmenopausal and/or not at high risk for cervical or vaginal cancer. Before July 1, Medicare only covered these screening services every three years.
Meanwhile, Medicare still covers an annual screening Pap smear and pelvic exam for women of childbearing age who have had an abnormal Pap smear within three years or are considered at high risk for cervical or vaginal cancer, notes Baker.
"Medicare considers a woman at high risk if she has a prior history of cancer or sexually transmitted disease; began having sexual intercourse before age 16; has had more than five sexual partners; has not had a Pap smear within seven years; or has a mother who used diethylstilbestrol during pregnancy," he says.
For a screening Pap smear, use HCPCS code Q0091 to report the process of obtaining and preparing the specimen and conveying it to the laboratory. Medicare will pay $38.26 for this code, which will vary somewhat by region, when the specimen is obtained in your office or other outpatient setting.
Medicare pays you separately for obtaining a specimen for a screening Pap smear during a patient office visit or other evaluation and management (E/M) service.
Baker advises you append CPT modifier -25 to the E/M service to indicate that it is a significant, separately identifiable service performed on the same date as a specimen collection service.
For example, if a beneficiary visits your office for ongoing treatment of her chronic hypertension — a service consistent with a midlevel established patient office visit (CPT 99213) — and you obtain a specimen for a screening Pap smear during that visit, bill 99213-25 in addition to HCPCS Q0091, he says.
Use HCPCS G0101 to report a pelvic exam, Baker advises. The Medicare 2001 payment rate for G0101 is $39.41, which also will vary a little by region.
Medicare will pay separately for a screening pelvic and clinical breast exam (G0101) and for obtaining a specimen for a Pap smear (Q0091) when the two services are billed together for the same patient on the same date. In turn, Medicare will pay for both G0101 and Q0091 when they are billed with an E/M service, as long as the E/M service is appended with modifier -25.
Medicare still pays separately for a pelvic and clinical breast exam performed during a medically necessary office visit, even if you do not obtain a specimen for a screening Pap smear. Append the E/M service with modifier -25 and also bill G0101 for the pelvic and clinical breast exam.
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