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Medicare Billing for a Well Woman – G0101, Q0091, G0438, G0439, 99387 & 99397

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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 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, assessment risk of future medical problems, promoting a healthy lifestyle, and to update 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 Annual Wellness Visit AWV

Yes.  The annual 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 is not billable.

2. Can you bill an annual with a V72.31 Annual Gynecological Exam diagnosis and get paid separately? No.  If you have already billed out an annual in a given year (V70.0) 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 comes 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 the CMS website, the ICD-9-CM Codes billable with the G0101 are V76.2, V76.47, V76.49, V15.89, and V72.31.  Select the appropriate codes.

i. V76.2 Special screening for malignant neoplasms, cervix
ii. V76.47 Special screening for malignant neoplasms, vagina
iii. V76.49 Special screening for malignant neoplasms, other sites
iv. V15.89 Other specified personal history presenting hazards to health
v. V72.31 Routine gynecological exam

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

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 ICD-9-CM Codes billable with the Q0091 are V76.2, V76.47, V76.49, V15.89, and V72.31.  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 V76.51 Special Screening for Malignant Neoplasms; Colon.

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 V15.89 diagnosis and the appropriate health history hazard (example: V10.3 History of Breast Malignancy).  Any V15.89 diagnosis is considered high risk and also eligible for the yearly G0101 and Q0091.

Advanced Beneficiary Notices (ABNs)

An Advanced 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 an annual.

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. Patient’s name, specific service and estimated charge amount must be listed on the ABN
3. 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.  When an ABN may be required but was not obtained this modifier should be applied.

Billing a Well Woman Exam

Fee for Service

Since 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 since they are allowable and reimbursable by Medicare.  The remainder 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:

CODE DESCRIPTION FEE
99397 Routine Annual Exam – Established pt 65 and older $142.35
G0101 Pelvic/Breast Exam $41.96
Q0091 Papsmear Collection $50.69
TOTAL $235.00

 

It is the same original fee for the 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 with a signed ABN that is billed out to Medicare:

Code Modifier Diagnosis
99397 GY V72.31
G0101 GA V76.2
Q0091 GA V76.2
82270 GA V76.2
81002 GY V72.31

Reference

Medicare billing policies are constantly changing at CMS and with your local carrier so before your 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 Services which 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.

Medicare Billing Services

47 Responses to “Medicare Billing for a Well Woman – G0101, Q0091, G0438, G0439, 99387 & 99397”

  1. Angie T says:

    I have a question regarding the V15.89 dx code. We have a LOT of our Medicare patients that refuse to answer the sexual history questions, therefore the providers can’t honestly say if they are high risk or not. Can I still use the V15.89 since the patient refuses to provide the information needed to determine if they need the well woman exam annually or biannually?

    • Angie if the patients are refusing to answer the sexual history section in your health questionnaire, then you should not utilize V15.89 on any claims you submit to Medicare. However if, based on the discussion between the provider and the patient, there is documentation in the patient’s health history from the provider about the patient’s high risk status then the V15.89 dx code could be applied.

      Are your docs asking about sexual history if the patient does not answer the questionnaire? They should be.

  2. Janine says:

    When using the -GY modifier for services not covered by Medicare, does the secondary insurance companies typically pay for the CPT with the -GY modifier, or do they also state it would be patient responsibility?

    • Janie that depends. Some secondaries do cover some services and procedures that Medicare does not. It really all depends on the individual policy the patient has. So even if you put a GY modifier it may pay. . . or not.

  3. […] Services (CMS) document entitled, Screening Pelvic Examinations, on the Medicare Learning Network, G0101 is payable when at least 7 of the following 11 elements are included and documented in the […]

  4. CAPRICE says:

    Mr. Oliverez,

    I was wondering about the difference between the 99387 and G0439. Our provider does not see many Medicare patients. You stated “They are two distinct services. You can always bill both if your doc did both services”. How are they different?

    • Here are the requirements for the twp services.

      A Preventive Medicine Services of Routine Physical Exam 99387/99397 consists of:
      - Review of Systems
      - Past Medical, Family and Social Histories
      - Age and Gender Appropriate Comprehensive Physical Exam
      - Counseling/anticipatory guidance/risk factor interventions

      The Medicare Annual Wellness Visit G0438/G0439 consists of:
      - Medical and family history
      – List of current medical providers
      – Height, weight, BMI, BP and other appropriate routine measurements
      – Detection of cognitive impairment
      – Review risk factors
      – Review of functional ability
      – Establish a written screening schedule for next 5-10 years
      – Establish list of risk factors
      – Provide advice and referrals to health education and preventative counseling services

      Note that there is no review of systems or physical exam for an AWV. Additionally you must cover and document all elements of the AWV to be billable.

  5. Maria says:

    I am billing a Medicare pt for V72.31 and V70.0, should I bill with a 99387 and/or the G0439? We also billed the G0101 with dx V76.2. I know Medicare will deny the 99387, but could we get paid for the G0439?

    • Hello Maria –

      As to which code to bill, a 99387 or a G0439, what service was performed by the physician, a New Patient Routine Physical Exam(99387) or a Subsequent Annual Wellness Visit(G0439)? They are two distinct services. You can always bill both if your doc did both services.

      Billing G0101 with V76.2 seems appropriate. Did you collect a pap smear also. If so you could bill Q0091 with V76.2. Yes Medicare will not cover 99387 but you can get paid for it. Medicare allows you to bill the patient for a Routine Physical Exam 99387/99397. You just have to carve-out any payment from Medicare for G0101 and Q0091 from what you bill the patient for the 99387.

      We bill Medicare patient for the Routine Physical Exam all the time with now problem. You don’t even need to have them sign an ABN, although I strongly suggest that you do to let them know they will be getting a bill.

      Hope this helps –Manny

  6. Craig Stinson says:

    I am new to billing, my question is – currently we are billing the Q0091 for a male pap. Obviously this is for women only. How can we bill properly for the visit and male pap? I was told to use the 99000. Isn’t that too vague of a code for Miscellaneous Services? Will 2014 CPT’s have a male pap code so we can be reimbursed properly from Medicare? I have hundreds of denials for this code and need to get these billed properly for Medicare. Thank you!

    Craig

  7. Maria says:

    I have patients that have Medicare primary and Medicaid as secondary, how do I bill the claims to Medicaid Ohio when Medicare denied the claim. I know the Q0091 and G0101 are Medicare codes only, so would I use the S0612 to bill to Medicaid? Also i billed CPT 99396, G0101, and Q0091 to Medicare and was only paid on the G and Q code, can I still bill the 99396 to Medicaid? After I crosswalk the code to use a covered charge?

    • Maria –

      You would still bill the Q0091 and G0101 but in our experience usually what reimbursement we get from Medicare is it. My bigger question is why were the codes denied. Medicare usually pays those codes with no problems. Was there a frequency issue. If so there is no chance Medicaid will pay. Did you get an ABN signed to be able to bill the patient? Also typically we see 99397(65 years and older) and not 99396 (40-64 years). Either way Medicare will not cover these preventative care visits. They can be, and should be, billed directly to the patient once the Q & G codes are carved out for pricing.

  8. Tarnesha McRae says:

    Can we bill an AWV and an OV the same same day. If so, how should we bill my example

    G0101-GA v76.2
    Q0091 v76.2
    99213-25 627.4

    • Tarnesha –

      Yes you can bill an Office Visit on the same day as the AWV. Based on what you mentioned and without seeing any notes, one way may be, if properly documented with an ABN and if you did a full physical exam:

      99387-GY V70.0
      G0438-GA V70.0
      99213-25 627.4
      G0101-GA V76.2
      Q0091-GA V76.2

  9. Venita Milburn says:

    Mr Oliverez

    I am new to GYN billing and having a terrible time getting Medicare claims to be accurate. I have billed the G0101 and Q0091 codes as appropriate per the notes and get paid for these. I have started having the front desk have patients sign ABNs. My question lies within the visit code either a 99387 or 99397 with the ABN modifier according to what I have read. I have also begun billing G0439 on some cases.

    Scenerio:

    Patient comes in for annual well woman check. ABN is signed. Physician performs a review of all systems, breast and pelvic exam (pap may or may not be obtained).

    Would I not bill the G0439, GY ; G0101 ; Q0091? or instead of G0439 would I bill the 99387 code?

    This has been very frustrating to me and I am looking for the correct, acceptable way to bill this.

    Thank you,
    Venita Milburn

    • Hello Venita and thanks for your question. First I want to make sure that we are on the same page. CPT codes 99387 and 99397 are not covered by Medicare and are billable to the patient. According to Medicare the patient doesn’t even need to sign an ABN for these services but as a practical matter we do have our practices present a “Voluntary ABN” for these services to the patient. Its good customer service to let them know they will be getting a bill.

      A G0439 and a 99387 are not the same services and you can bill them both together if both services are done so in your scenario I am not sure how to bill it without seeing the notes. But lest say that the doctor performed a full routine physical along with a subsequent Annual Wellness Visit on an existing Medicare patient. Plus a pap and breast 7 pelvic exam and on top of that the patient had a sore throat that turned out to be strep and the doc prescribed an antibiotic.

      this is how I would bill the visit:

      99387 V70.0 $165.96
      G0439 V70.0 111.94
      99213-25 034.0 72.81
      G0101 V72.31 38.11
      Q0091 V72.31 45.93
      TOTAL $434.75

      Since the routine physical is not covered Medicare has you care out the G0101 and Q0091 reimbursements they will make from what you charge the patient for the 99387. So if you charge $250 for 99387 you must subtract the payments from the G0101, $38.11 , and Q0091, $45.93 , since they are included in 99387 and bill collect from the patient $165.96. I used Medicare national pricing.

      So in my scenario you would get reimbursed from Medicare and the patient a total of $434.75 for the visit.

      Did you download my Billing a Well Woman Exam to Medicare report? If not CLICK HERE to download it. It contains more detailed information.

      Not sure if this helps or is more confusing. Please let me know — Manny

  10. Dori says:

    If I have a nurse who is doing this and she codes:
    99213
    Q0091
    V70.0
    V72.31
    401.1
    What is the correct way a nurse practitioner should be billing for this?

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  12. NORMA G. says:

    I am a year into this billing job and we don’t have many medicare patients, but I seem to be having problems with sending claims out to medicare and them receiving them. Can you please guide me to get the claims address and a GOOD phone number for me to ask questions.

    Thank you,

    Norma

  13. sophia says:

    How would i bill for an annual breast exam without the pelvic exam?

  14. [...] using code G0402 for the Initial Preventative Physical Exam (IPPE), Annual Wellness Visit codes, and How to Bill a Well Woman Exam to Medicare using CPT codes 99387, 99397, G0101, Q0091, G0438 and [...]

  15. Christine says:

    In our Comprehensive Breast Center, our Nurse Navigation program would like to create a program for clinical self breast exams. Is there a CPT code for this?

    Thank you!

  16. Linda says:

    I have G0438 with a 25 modifier Q0091 no modifier and G0101 with 59 modifier no GA on claim and the V72.31 was the dx codes. Bravo rejected G0101 wanted the claim resubmitted with appropriate modifier or missing modifier. Is there another modifer that can be used in order to get claim processed?

    • You know Linda I think the modifiers are what is messing up the claim. We do not use modifiers on these codes when we submit claims. Check with your local Medicare carrier on the specifics in your jursidiction on how to properly bill these codes and try again.

  17. Elizabeth Palace says:

    The patient was supposed to have a wellness exam G0439 instead she had a 99397 was coded. She also had a pap. Is the patient now responsible?

    • Elizabeth that would depend. By only coding 99397 your doc is stating two things:

      1. The patient did not have an Annual Wellness Visit (AWV)
      2. A Complete Routine Physical Examination was performed (99397)

      Since your have questions on the code that was billed you should take a look at the documentation for the visit. Maybe there was an AWV performed and a 99397. In that case you could bill the G0439 (Subsequent AWV) and the 99397 together. Maybe it was coded wrong and it really should be G0439. There is no way to know without reviewing the chart notes. The notes is where I would start looking. Remember that an AWV is not a Routine Physical and cannot be coded as such.

      So if it turns out to be a 99397 then the patient would be responsible. The Pap should be billable to Medicare so don't forget to carve-out the price of the Pap (Q0091) from the 99397 before you would bill the patient. Also get your Medicare patients to sign an Advanced Beneficiary Notice (ABN) for applicable service.

      The CMS website has a quick reference guide for Medicare Preventive Services which lists applicable tests, diagnoses and frequencies. CLICK HERE to get it. –Manny

  18. Raquel Canales says:

    I dont have or do twtter. How else can I communicate with Manny if I have other questions? I'm working for a PCP office for the first time & lost on alot of the billing.

  19. Yajaira says:

    When billing Q0091, can dx V15.89 be a primary dx?

  20. R. Jeria says:

    Can someone help me,
    We are going to start providing Clinical Breast Exams prior to mammograms in the mammography department and want to know how we can bill for this service.

    What is the billing code to be used for a physical breast exam only?

    Can a mammography technologist who is certified to perform Clinical Breast Exams bill for the physical breast exam?

    If so what billing code should be used?
    and what diagnosis codes are appropriate to use?

    (We are located in Missouri if that matters)

    If nobody knows this answer do you know where I can find the answer?

  21. Cori says:

    If Medicare does not pay for 99387 & 99397, what would be the purpose of billing for those codes if Medicare does cover the annual wellness visits when billed using codes G0438 and G0439?

    • The Annual Wellness Visit codes G0438 and G0439 do not include the components of a Routine Preventative Exam. Therefore you can bill for both at the same time if the provider performs both services and documents them accordingly. Cori, you are correct that 99387 and 99397 are non-covered services and Medicare not will pay for them, however, you are still allowed to bill for the Routine Exam. You do not need an ABN to bill the patient as it is not required by Medicare for most preventive services but we do have our practices give a voluntary ABN to their patients so that they know the exam will ultimately be their financial responsibility. Additionally, several secondary insurance companies do pay for the routine annual exam even though Medicare will not.

  22. Krissia Ramos says:

    I have to bill a wellness exam, how should I code that?

    • Krissa are you asking about a Routine Well Exam? If so, that would be billed using a 99387 or 99397 depending if it is a new patient or existing patient. A diagnosis code of V70.0, routine physical exam, would be appropriate. Routine exams are a non-covered service by Medicare so the patient would be responsible for the entire amount. There is a calculation if you are also doing a Pap, pelvic and breast exam where you carve out those procedures and bill them separate from the routine exam. You should also add a GZ modifier.

      Come back to the website in a couple of weeks. We are giving away a booklet on how to bill a routine exam with a well woman exam to Medicare. Also look at other posts on our website about billing Medicare. If you were asking about the Annual Wellness Visit (AWV) check out my post, http://www.capturebilling.com/medicare-g0438-g043…. If you were asking about the Welcome to Medicare exam see http://www.capturebilling.com/welcome-to-medicare… .

      The best thing you can do is go to your local Medicare carrier website. There you will find information on exactly how to bill for these and other procedures.

  23. Shelly Peterson says:

    If a patient is having their Medicare annual exam at the same time would you bill out this way:

    G0402
    Q0091GA
    G0101GA

    • YES. The parameters of the G0402, Welcome to Medicare exam, are very specific. Remember a G0402 is not an "annual exam”. The G & Q codes can be billed with the G0402. The GA signifies you have a valid ABN on file. Billing as you’ve listed is appropriate as long as you have met the docmentation and medical necessity requirements.

      • maud says:

        Hi Manny,
        Why would you append a GA modifier on these claims, Medicare does cover for these services. G

        • Great question. Yes Medicare does cover Q0091 and G0101 but there are some restrictions. Medicare states these test can be performed . . .

          \”Annually if at high risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within
          past 3 years. Every 24 months for all other women.\”

          Let\’s say a woman comes to your practice as a new patient and you perform and bill the G0101, Pelvic and Breast Exam and Q0091, Pap smear, and do not have an ABN signed because it is a covered service. You then submit the claim to Medicare and two weeks later you receive a denial from Medicare stating the procedures are not covered due to coverage limitations and you cannot bill the patient because you do not have an ABN on file.

          So what happened? It\’s a covered service right?

          Well that last well woman exam the patient thought they had 3 years ago was actually 22 months ago. As you can see Medicare only coveres these services every 24 months. Thus a denial and the service becomes non-covered.

          If there was an ABN on file, which you would have indicated by using the GA modifier, Medicare on the EOB would state that the service could be billed to the patient.

          No ABN and GA modifier in this senerio would lead to no payment for the service you physician provided.

          We advise all our practice to obtain an ABN and to make sure that the ABN is filled out properly to be valid.

          Please let me know if this helps. -Manny

          • David E. Kim, M.D. says:

            Does it have to be exactly 365 days at least to bill the annual codes by a PCP/internal medicine like me? Examples if I saw and billed a annual visit and billed the 99397 and G0438 2/13/13 and then bill for it 1/2/2014 will I be paid? PS this a very useful and informative site. Thanks. Dr Kim

          • Dr. Kim thank you for your kind words.

            Yes you must wait one full year before before billing another Annual Wellness Visit. So if you billed a 99397 with a G0439 on January 2nd then you will not be paid for the AWV as it was done within a year of doing the initial AWV G0438. Of course you still have the fee you collected from the patient for the 99397 routine physical exam. You did collect that correct?

  24. Manny Oliverez says:

    Remember the G0101 and the Q0091 are Medicare codes to use when you carve out the breast/pelvic exam and PAP from the well exam. For regular commercial insurance there is no carve out and the breast/pelvic exam along with the pap smear collection are included in 99397. You can however bill for the lab specimen transfer fee 99000 to send the sample to the lab and for the wet preps if you do them.

  25. Cheryl says:

    Manny,
    We are looking into doing Well Women's pelvic and breast exams in our office. We are a PCP office.
    Will the insurance companies combine 99397 and G0101 as one procedure..but will they pay the PAP collection along with the 99397.

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