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?
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.
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: http://www.cms.gov/MLNProducts/Downloads/MPS_QuickReferenceChart_1.pdf
CPT copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Getting Started
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.
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.
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.
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
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.
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.
thanks for giving information
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?
When billing Q0091, can dx V15.89 be a primary dx?
We have billed using V15.89 as the primary diagnosis followed by the ICD-9 code giving the reason for the high risk and have gotten paid.
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.
Go to Facebook or give me a call.
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
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.
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!
How would i bill for an annual breast exam without the pelvic exam?
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
Norma the information you need should be on your local Medicare website. Where are you located? What is the name of the local Medicare carrier?