Ob-Gyn Coding Alert - Billing for Pap Smear
Physcians are often confused when it comes to billing pap smears. Finding the correct CPT code for pap smear isn’t easy.
Billing for Pap Smear
Physcians are often confused when it comes to billing pap smears. Finding the correct CPT code for pap smear isn’t easy.
- Pap smear can be diagnostic or screening services
- Pelvic is part of preventive visit or problem-oriented E/M visit
- New add-on code in 2024, +99459 pelvic exam code
Physicians are always curious about what codes they should use when billing for pap smears during preventive visits or problem visits. The only CPT codes related explicitly to Pap smears are used by pathologists, who interpret the cytology specimen. Office physicians who collect Pap smears should not use CPT codes in the series 88000 for the lab section.
What Should Be Billed For Pap Smears Performed In A Gynacologist or Primary Care Practitioner Report for Doing a Pap Smear at a Visit?
It is important to determine whether the test is screening or diagnostic before answering this question. A screening test is performed when no symptoms align with preventive guidelines. In contrast, a diagnostic test is conducted due to a sign or symptom, an existing condition, or a previous abnormal test result. Additionally, two HCPCS codes for screening services are outlined below.
Scenario 1 - Pap Smear During a Problem-Oriented Visit
If a patient presents with a condition or complaint, such as discharge, pelvic pain, or dysfunctional uterine bleeding, the practitioner does a pelvic exam and collects a Pap smear. In that case, the practitioner bills an E/M service only. Select the level of E/M service based on the key components of history, exam, medical decision-making, or time if counselling dominates the visit.
Do not report Q0091 to report a diagnostic Pap smear that is performed due to illness, disease, or symptoms
For example, The patient presents with dysfunctional uterine bleeding, and as part of the evaluation, the clinician performs a Pap smear. screening Pap smear because the purpose of the visit and the Pap is not screening but diagnostic. The pelvic exam conducted by the provider is included as part of the E/M service and cannot be billed separately during a problem-oriented visit. Billing the HCPCS code Q0091 for obtaining a Pap smear would be incorrect. This is because the purpose of the visit and the Pap is diagnostic, not screening.
Pap Smear During a Preventive Medicine Service for a Commercial Patient
Suppose the patient presents for a preventive medicine service. In that case, the pelvic exam is included as part of the age and gender-appropriate physical exam described by CPT codes in the 99381 to 99397 series. The HCPCS code Q0091, which covers obtaining the screening Pap smear, may be used for a screening Pap smear. Although Q0091 is a Medicare-specific HCPCS code, many commercial payers also recognize it.
Do not bill G0101 for a pelvic and clinical breast exam on the same day as a CPT preventive visit.
This is because, the CPT codes 99381–99397 already include age- and gender-appropriate history and physical exam, so billing G0101 would constitute double billing for that portion of the exam.
- G0101: Cervical or vaginal cancer screening; pelvic and clinical breast examination.
- Q0091: Screening Pap smear; obtaining, preparing, and conveyance of the cervical or vaginal smear to the laboratory.
- +99459: Pelvic examination (to be listed separately in addition to the code for the primary procedure).
+99459 Pelvic Examination
CPT introduced code +99459 in 2024 as an add-on for new and established patient visit codes (99202–99205, 99212–99215), consultation codes (99242–99245), and preventive medicine codes (99381–99397). This code includes the physician fee schedule without wRVUs and covers the practice expense for performing a pelvic exam. This code is valued based on 4 minutes of staff time and a supply kit costing $20. While this does not guarantee a $20 payment explicitly, it reflects the national cost factored into the code's valuation.
According to "The AMA’s CPT Changes 2024: An Insider’s View," code +99459 was established to capture additional costs associated with performing a pelvic exam. While the resource does not specify that a staff member must be present for billing, the January CPT Assistant notes that the practice expense primarily accounts for the clinical staff time needed to chaperone the examination. Additional staff time is also required for setting up the room and, if a Pap smear is performed, preparing and transmitting the specimen.
The total RVUs for this code are 0.68 in both facility and non-facility settings. The national reimbursement rate is approximately $22.26 based on a conversion factor of $32.74.
This code can be used for both preventive and problem-oriented visits. Although neither CPT nor CMS in the Final Rule specifies diagnosis coding, the code should be used for the primary E/M procedure.
Pap Smear During a Medicare Wellness Visit
Medicare does not cover routine services but does provide coverage for cervical/vaginal cancer screenings along with a breast exam. This service can be performed annually for patients with high-risk diagnoses and every two years for those with low-risk diagnoses. Table of High and Low risk codes are here given below:
High-Risk Diagnosis Codes
| Code | Description |
|---|---|
| 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 |
Low-Risk Diagnosis Codes
| Code | Description |
|---|---|
| Z01.411 | Encounter for gynecological examination (general) (routine) with abnormal findings |
| Z01.419 | Encounter for gynecological examination (general) (routine) without abnormal findings |
| 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 |
| Z91.89 | Other specified personal risk factors, not elsewhere classified |
| Z92.89 | Personal history of other medical treatment |
Components of G0101
G0101 requires a breast exam and a total of 7 exam elements, with the breast exam being necessary to report G0101:
- Digital rectal examination assessing sphincter tone, presence of hemorrhoids, and rectal masses
- Examination of the external genitalia
- Urethral meatus inspection
- Urethra evaluation
- Bladder assessment
- Vaginal examination
- Cervix inspection
- Uterus examination
- Adnexa/parametria evaluation
- Anus and perineum inspection
There is no separate code for performing the breast exam alone on a Medicare patient who does not require the full range of screening exam elements included in G0101.
Key Takeaways Of Pap Smear Billing Guideline
- Use the 99381-99397 series and Q0091 for preventive medicine services, which may include performing a screening Pap smear.
- When using E/M codes for a symptom or condition and a Pap smear is obtained, report only the E/M service. Do not report Q0091 in this scenario, as it is specifically for obtaining a screening test.
- For Medicare patients receiving a screening pelvic and breast exam along with a screening Pap smear, use codes G0101 and Q0091. Be aware of the frequency limits set for these services.
Why Choose BillingFreedom For OBGYN Billing And Coding?
Choose BillingFreedom for OBGYN billing and coding to ensure accuracy, efficiency, and maximum reimbursement. With specialized expertise in OBGYN billing, we handle complex coding challenges, including maternity, prenatal, and gynecological services. Our team stays updated on the latest coding changes, reducing claim denials and ensuring compliance with regulations. We offer customized solutions to meet your practice's unique needs, from handling high-volume claims to providing detailed reports for financial transparency.
Trust BillingFreedom to streamline your billing processes, minimize errors, and enhance your practice’s revenue cycle, allowing you to focus on patient care.
For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472. Your financial tranquility is our priority!
Ready to Boost Your Revenue?
Save your hard earned money, register, before it's gone.