Medicare Billing for Well Woman Exam - Codes G0101 Q0091 (2024)

Medicare Billing for Well Woman Exam Using Codes G0101 and Q0091 and Annual Wellness Visits AWV G0438 and G0439

As we are all aware, Medicare now allows for the Annual Wellness Visit (AWV) G0438 or subsequent AWV G0439, but how does this relate to an annual Well Woman Exam? IT DOESN’T.

An annual Well Woman Exam is a completely separate evaluation and management service from an AWV, and unless the provider specifically evaluates a patient for both the AWV and a Well Woman Exam, the AWV should not be billed out. So, how does a provider bill out for an annual Well Woman Exam for a patient covered by Medicare? Let’s discuss the components of the Routine Annual Preventive Physical Exam (sometimes call an Annual Exam) first.

What does an Annual Exam include?

Preventive Medicine Service codes are defined by the CPT book as evaluation or reevaluation and management of an individual, including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.

The purpose of the annual exam includes screening for disease, assessing risk of future medical problems, promoting a healthy lifestyle, and updating vaccinations. Aspects of the annual exam may include all or some of the following:

1. Review of History
2. Checking Vital Signs
3. General Appearance
4. Heart Exam
5. Lung Exam
6. Head and Neck Exam
7. Abdominal Exam
8. Neurological Exam
9. Dermatological Exam
10. Extremities Exam
11. Males: Testicular and Prostate Exams
12. Females: Breast and Pelvic Exams
13. Counseling
14. Routine Laboratory Tests
15. Immunizations

Does an Annual Exam also include a Well Woman Exam?

Medicare Billing for Well Woman Exam - Codes G0101 Q0091 (1)

Yes. The Routine Annual Preventive Physical Exam also includes the components of a Well Woman Exam. If a patient is seen by her primary care physician (PCP) for an annual, the provider will also include the pelvic and breast exam and a Pap smear collection. If the patient elects to have the Well Woman Exam performed by her gynecologist, the PCP must document that the pelvic and breast exams and pap smear collection were deferred, and will be performed by a gynecologist.

Incorrect Billing Procedures

1. What if you run out of time? If the patient is seen for an annual and the Well Woman Exam portions are not done during the same visit, the provider may need to see the patient again in order to complete the comprehensive exam. This second visit is merely a continuation, and it is not billable.

2. Can you bill an annual with Z01.411, Encounter for gynecological examination (general) (routine) with abnormal findings, orZ01.419,Encounter for gynecological examination (general) (routine) without abnormal findings, and get paid separately? No. If you have already billed out an annual in a given year (Z00.00, Encounter for general adult medical examination without abnormal findings or Z00.01, Encounter for general adult medical exam with abnormal findings), then you cannot charge another annual with a different diagnosis.

3. What if the patient did not want the Well Woman Exam portions done during the regular annual? If the patient did not want the pelvic/breast exam and pap smear collection during the routine physical, but later decided to not see the gynecologist and came back for these screenings, you still cannot bill for these separately. They are already included in the annual. The patient may be seen, but it cannot be billed.

Requirements of Coding and Billing an Annual Well Woman Exam to Medicare

Medicare does not cover preventive services, such as an annual (besides the AWV), but certain Well Woman Exam screenings are reimbursed either every two years or annually.

Covered Services

Medicare covers the following screening exams in conjunction with a Well Woman Exam:

1. G0101 Cervical or Vaginal Cancer Screening; Pelvic and Clinic Breast Examination

a. G0101 is reimbursed by Medicare every two years unless the patient is considered high risk, and then it is allowed on an annual basis. You must document a minimum of 7 of the 11 elements.
b. According to the CMS website, the following ICD-10-CM codes are billable with G0101. Select the appropriate codes.

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings [Use additional code(s) to identify abnormal findings]Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z11.51 Encounter for screening for HPV (primary)
Z12.4 Encounter for screening for malignant neoplasm of cervix
Z12.72 Encounter for screening for malignant neoplasm of vagina
Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
Z12.89 Encounter for screening for malignant neoplasm of other sites
Z72.51 High-risk heterosexual behavior
Z72.52 High-risk homosexual behavior
Z72.53 High-risk bisexual behavior
Z77.29 Contact with and (suspected) exposure to other hazardous substances
Z77.9 Other contact with and (suspected) exposures hazardous to health
Z91.89 Other specified personal risk factors, not elsewhere classified
Z92.89 Personal history of other medical treatment

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

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings [Use additional code(s) to identify abnormal findings]Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z11.51 Encounter for screening for HPV (primary)
Z12.4 Encounter for screening for malignant neoplasm of cervix
Z12.72 Encounter for screening for malignant neoplasm of vagina
Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
Z12.89 Encounter for screening for malignant neoplasm of other sites
Z72.51 High-risk heterosexual behavior
Z72.52 High-risk homosexual behavior
Z72.53 High-risk bisexual behavior
Z77.29 Contact with and (suspected) exposure to other hazardous substances
Z77.9 Other contact with and (suspected) exposures hazardous to health
Z91.89 Other specified personal risk factors, not elsewhere classified
Z92.89 Personal history of other medical treatment

a. Q0091 is reimbursed by Medicare every two years unless the patient is considered high risk, and then it is allowed on an annual basis.
b. Per the CMS website, the following ICD-10-CM Codes are billable with Q0091. Select the appropriate codes.

3. 82270 Fecal Occult Blood Test

a. 82270 can be billed on an annual basis.
b. Per the CMS website, the appropriate code varies by carrier. An applicable code is Z12.10 Special Screening for Malignant Neoplasms; Colon.

For complete information see Medicare’s Screening Pap Tests & Pelvic Exams MLN Booklet.

High-Risk Factors and Frequency

High-Risk Factors determine whether or not a patient may have the G0101 and Q0091 on an annual basis. If a patient is considered high risk, then these screening tests may be done annually.

According to the CMS website, the following factors are listed as high-risk factors for screening pap smears and pelvic exams:

1. Cervical High-Risk Factors
a. Early-onset of sexual activity (under 16 years of age)
b. Multiple sexual partners (five or more in a lifetime)
c. History of a sexually transmitted disease (including HIV infection)
d. Fewer than three negative pap smears within the previous 7 years
2. Vaginal Cancer High-Risk Factors: DES (diethylstilbestrol) exposed daughters of women who took DES during pregnancy
3. Personal History of Health Hazards: If a patient has a specified personal history presenting hazards to health then apply the appropriate diagnosis codes considered high risk. Thismakes the patienteligible for the yearly G0101 and Q0091.

Advance Beneficiary Notices (ABNs)

AnAdvance Beneficiary Notice is a Medicare Waiver of Liability that providers are required to give a Medicare patient for services provided that may not be covered or considered medically necessary. ABNs do not apply to services that are specifically excluded from Medicare coverage, such as a Routine Annual Preventative Physical Exam.

A completed and signed ABN is key for reimbursement. It also notifies Medicare that the patient acknowledges that certain procedures were provided and that the patient will be personally responsible for full payment if Medicare denies payment for a specific procedure or treatment. If there is no signed ABN then you cannot bill the patient and it must be written off if denied by Medicare (translation: Free Services, Lost Revenue).

ABN Criteria

1. The ABN must be given to the patient prior to any provided service or procedure.
2. The patient’s name, specific service, and estimated charge amount must be listed on the ABN.
3. An ABN cannot be given to a patient who is under duress or requires emergency treatment.
4. Check for specific criteria and download the form at http://www.cms.gov/BNI/02_ABN.asp

Appropriate Medicare Modifiers

Certain Medicare modifiers are required when billing with an ABN.

1. GA Modifier: Waiver of Liability Statement Issued as Required by Payer Policy. This modifier indicates that an ABN is on file, and allows the provider to bill the patient if not covered by Medicare.

2. GX Modifier: Notice of Liability Issued, Voluntary Under Payer Policy. Report this modifier only to indicate that a voluntary ABN was issued for services that are not covered.

3. GY Modifier: Notice of Liability Not Issued, Not Required Under Payer Policy. This modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded.

4. GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary. This modifier should be applied when an ABN may be required, but was not obtained.

Billing a Well Woman Exam

Fee for Service

Because specific Well Woman screening components of the routine annual exam are covered by Medicare, these are billed out separately. These screenings are carved out from the provider’s usual fee for preventive service because they are allowable and reimbursable by Medicare. The remaining balance is the patient’s financial responsibility. The total fee does not change, only how it is billed and who pays.

The G0101 and the Q0091 are the services that are reimbursed and carved out of the regular annual fee. The Medicare reimbursement for the G & Q and patient portion equal the same annual fee that a non-Medicare patient would be charged.

For example, if the fee for an annual for a non-Medicare patient is $235.00, this is the breakdown for a Medicare patient:

CODEDESCRIPTIONFEE
99397Routine Annual Exam – Established pt 65 and older$142.35
G0101Pelvic/Breast Exam$41.96
Q0091Pap smear Collection$50.69
TOTAL$235.00

It is the same original fee but billed out differently.For additional clarification, please refer to ACOG’s Medicare Screening Services PDF.

Billing Medicare

Following is an example of a typical Well Woman Exam without abnormal finding with a signed ABN that is billed out to Medicare:

CodeModifierDiagnosis
99397GYZ01.419
G0101GAZ01.419
Q0091GAZ11.51
82270GAZ12.10
81002GYZ01.419

Reference

Medicare billing policies are constantly changing at CMS and with your local carrier, so before you do anything, check with them and your coding specialist to make sure you are billing correctly.

The CMS website has a quick reference guide for Medicare Preventive Servicesthat lists applicable tests, diagnoses, and frequencies. Check it out for more information.

CPT copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

As an expert in medical billing and coding, I can confidently provide insights into the intricacies of Medicare billing for well-woman exams and annual wellness visits. My expertise is derived from a comprehensive understanding of Current Procedural Terminology (CPT) codes, Medicare regulations, and best practices in medical coding and billing.

Firstly, it's crucial to highlight the distinction between Annual Wellness Visits (AWV) and Well Woman Exams. Medicare allows for AWVs under codes G0438 and G0439, but these are separate from Well Woman Exams. The Routine Annual Preventive Physical Exam, often referred to as an Annual Exam, encompasses a range of preventive medicine services with specific components outlined by CPT.

Key components of the Routine Annual Preventive Physical Exam include:

  1. Review of History
  2. Checking Vital Signs
  3. General Appearance
  4. Heart Exam
  5. Lung Exam
  6. Head and Neck Exam
  7. Abdominal Exam
  8. Neurological Exam
  9. Dermatological Exam
  10. Extremities Exam
  11. Males: Testicular and Prostate Exams
  12. Females: Breast and Pelvic Exams
  13. Counseling
  14. Routine Laboratory Tests
  15. Immunizations

Importantly, the Annual Exam already includes the components of a Well Woman Exam. Whether performed by a primary care physician (PCP) or a gynecologist, the pelvic and breast exams, as well as Pap smear collection, are integral parts of the annual exam.

Medicare covers certain screenings associated with Well Woman Exams, and they include:

  1. G0101: Cervical or Vaginal Cancer Screening; Pelvic and Clinic Breast Examination

    • Reimbursed every two years unless the patient is considered high risk.
  2. Q0091: Screening Papanicolaou Smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

    • Reimbursed every two years unless the patient is considered high risk.
  3. 82270: Fecal Occult Blood Test

    • Can be billed on an annual basis.

High-risk factors determine whether a patient may have G0101 and Q0091 on an annual basis. These factors include early-onset of sexual activity, multiple sexual partners, history of sexually transmitted diseases, and other specified personal risk factors.

Billing a Well Woman Exam to Medicare involves using specific CPT codes and modifiers. An Advance Beneficiary Notice (ABN) is essential for services that may not be covered, and appropriate Medicare modifiers (GA, GX, GY, GZ) are required when billing with an ABN.

Billing is done on a fee-for-service basis, with specific Well Woman screening components billed separately. The G0101 and Q0091 services are reimbursed by Medicare, and the remaining balance is the patient's responsibility.

In summary, accurate coding, adherence to Medicare guidelines, and proper use of modifiers are crucial for successful billing of Well Woman Exams to Medicare. It's important to stay updated with CMS guidelines and consult with coding specialists for any changes in billing policies.

Medicare Billing for Well Woman Exam - Codes G0101 Q0091 (2024)

References

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