Tuesday, May 31, 2016

CPT CODE G0123, G0141, P3000, P3001 AND Q0091 - covered ICD 10 CODE

Screening Pap Tests

HCPCS/CPT Codes

G0123, G0124, G0141, G0143, G0144,

G0145, G0147, G0148 – Screening  cytopathology, cervical or vaginal

G0123 - Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

P3000 – Screening Pap smear by technician under physician supervision

P3001 – Screening Pap smear requiring interpretation by physician

Q0091 – Screening Pap smear; obtaining, preparing and conveyance to lab


ICD-10-CM Codes

High risk – Z77.22, Z77.9, Z91.89, Z72.89,
Z72.51, Z72.52, AND Z72.53
Low risk – Z01.411, Z01.419, Z12.4, Z12.72,
Z12.79, and Z12.89


Who Is Covered

All female Medicare beneficiaries


Frequency
• Annually if at high risk for developing cervical or vaginal cancer or childbearing age with abnormal Pap test within past 3 years; or
• Every 2 years for women at normal risk


Beneficiary Pays

• Copayment/coinsurance waived
• Deductible waived


Indications and Limitations of Coverage and/or Medical Necessity

Screening Pap Smears, Pelvic and Breast Examinations 

A screening Pap smear and pelvic examination (including clinical breast examination) is covered by Medicare Part B for a woman if she has not had such an examination in the preceding 3 years (i.e., none paid by Medicare during the preceding 35 months following the month in which her last Medicare-covered screening pelvic examination was performed and found to be normal). Use ICD-9-CM code V76.2 to indicate low risk.

A screening Pap smear and pelvic examination (including clinical breast examination) is covered by Medicare Part B for a woman if she has not had such an examination in the preceding 1 year (i.e., none paid by Medicare during the preceding I 1 months following the month in which her last Medicare-covered screening pelvic examination was performed and found to be normal) when ordered by a physician (or authorized practitioner) under one of the following high risk conditions:

There is evidence (based on the medical history and other findings) that she is at high risk of developing cervical cancer and her physician (or qualified nonphysician practitioner) recommends that she have the test performed more frequently than every 3 years.

The woman is of childbearing age and has had a Pap smear during any of the preceding 3 years that indicated the presence of cervical or vaginal cancer or other abnormality.

High risk factors for cervical and vaginal cancer are:

Early onset of sexual activity (under 16 years of age);

Multiple sexual partners (five or more in a lifetime);

History of sexually transmitted disease (including the human immunodeficiency virus (HIV));

Fewer than three negative Pap smears within the previous 7 years;

Prenatal exposure to diethylstilbestrol - Exposed daughters of women who took

DES during pregnancy.


Use ICD-9-CM codeVl5.89 to indicate high risk.



C. A screening pelvic examination (including a clinical breast examination) (G0101) must include and document at least seven of the following eleven elements:

Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge.

Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses.

Pelvic examination (with or without specimen collection for smears and cultures) including:

External genitalia (for example, general appearance, hair distribution, or lesions)

Urethral meatus (for example, size, location, lesions, or prolapse)

Urethra (for example, masses, tenderness, or scarring).

Bladder (for example, fullness, masses, or tenderness).

Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)

Cervix (for example, general appearance, lesions, or discharge).

Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)

Adnexa/parametria (for example, masses, tenderness, organomegaly, or modularity)

Anus and perineum.


D. Screening Services Coverage and Reimbursement

Effective January 1, 1999, G0101 is allowed with an E/M visit if the visit is significant and separately identifiable service.

When both are appropriately provided at the same encounter, modifier 25 is appended to the E/M service code.

Effective April 1, 1999, Q0091 and a separately identifiable E/M service may be billed by the same physician on the same day. Modifier 25 is appended to the E/M service code. In this circumstance, the Part B deductible would apply to the E&M service.

For routine physical exams or preventative medicine services (99381-99499) furnished in conjunction with a medically necessary visit or covered screening pelvic exam, the following apply:

The physician may bill Medicare for a significant and separately identifiable service, using an evaluation and management E/M code.

Limiting charge, assignment and deductible rules apply to the covered portion of the visit.
The beneficiary may be billed for the non-covered portion of the visit using the preventive service E/M codes.

The amount that may be billed to the beneficiary, for the portion the of noncovered the visit, must be the amount by which provider’s current established visit charge for exceeds his/her established the noncovered charge for the service.covered.

Medicare Part B payment is made for the covered service as the lesser of the fee-schedule amount and the physician’s actual charge for the service.

Advance notice of non-coverage to the beneficiary is not required because Medicare coverage of routine physical examinations is denied on the basis of statutory exclusion.

Effective 01/01/98, the Part B deductible for screening Pap smear and pelvic examination services paid under the physician fee schedule is waived, subject to certain frequency and payment limitations.

G0123, G0143, G0147, G0148 and P3000 are paid under the clinical diagnostic laboratory fee schedule.

G0124, G0141 and P3001 are paid under the physician fee schedule.



Diagnostic Pap Smears 

Diagnostic Pap Smears may be covered for the following conditions:

Previous cancer of the cervix, uterus, or vagina that has been or is presently being treated;

Previous abnormal Pap smear;

Abnormal findings of the vagina, cervix, uterus, ovaries, or adnexa;

Any significant complaint by the patient referable to the female reproductive system; or

Any signs or symptoms that might in the physician’s judgment reasonably be related to a gynecologic disorder.

The physician performing the test would determine which method (monolayer cell preparation collected in preservative fluid, TBS or other) is medically necessary to  achieve the best results for screening or diagnostic Pap smears.

Limitations:

CPT/HCPCS procedure codes G0124, G0141, P3001, and 88141 are payable by the Part B carrier in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24), and independent laboratory (81).

CPT/HCPCS procedure codes G0123, G0143, G0147, G0148, P3000, 88142, 88143,88147,88148,88150,88152,88153,88154,88155,88164,88165,88166, and 88167 are payable by the Part B carrier in the following places of service: office (11), ambulatory surgical center (24), and independent laboratory (81).

CPT/HCPCS procedure code G0101 is payable in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24), skilled nursing facility (31), nursing facility (32), and custodial care facility (33).

CPT/HCPCS procedure code Q0091 is payable in the following places of service: office (11) and ambulatory surgical center (24).


Deductible and Copayment/Coinsurance waived (when billed with appropriate diagnosis code): 

* Screening Pap Tests (G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091)

* Screening Pelvic Examinations (G0101)

Providers must report one of the following diagnosis codes for a screening pelvic examination and/or screening Pap test:

* High Risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within past 3 years will be covered annually: V15.89 (ICD-10-CM DRAFT CODES; EFFECTIVE 10/01/2015: Z77.128, Z77.21, Z77.9, Z91.89, Z92.89)

* Low Risk covered every 24 months: V72.31, V76.2, V76.47, V76.49(ICD-10-CM DRAFT CODES;

EFFECTIVE 10/01/2015: Z01.411, Z01.419, Z12.4, Z12.72, Z12.0, Z12.79, Z12.89)

Beginning January 1, 2014, Paramount will follow Medicare guidelines and will no longer cover preventive services identified in the CPT code range 99381-99397 for Paramount Elite members. Medicare discontinued coverage of the above mentioned codes January 1, 2011 and offered alternative HCPCS codes. At times, providers may perform well-woman services in addition to a problem-oriented E/M service. If Q0091 and G0101 are reported solely for the purpose of an unrelated screening service, they may be separately reimbursed in addition to the problem-oriented E/M service. The documentation must clearly support a significant, separately identifiable service.


Reimbursement Guidelines

A. For Moda Health Medicare Advantage plans:

The provider performing the Pap/pelvic/breast exam visit may submit procedure codes G0101 and Q0091.

* G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination)

*  Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory)

If a screening rectal exam is performed as part of the Pap/pelvic/breast exam, it is considered incidental and may not be separately reported.

The laboratory performing the Pap test may bill the appropriate lab and pathology procedure code(s) for examining the Pap smear specimen (e.g. 88141-88155, 88164-88167, 88174- 88175).

Preventive medicine codes (e.g. 99397, 99397-52) billed with a gynecological diagnosis code (e.g. ICD-9 V72.31 or ICD-10 Z01.419) will be denied as a provider write-off.

Additional preventive services (e.g. a screening rectal exam, a health risk assessment, ordering covered preventive/screening labs and tests, or other assessment of a non-symptomatic Member) are covered as part of an annual comprehensive preventive exam under the Member’s Annual “Wellness” visit benefit.

* Do not request a pre-service organizational determination of non-coverage in order to have the member pay for these services out-of-pocket, as these are not non-covered services.

* These services are covered as part of the Annual “Wellness” visit, but are not part of a Pap/pelvic/breast exam.

Report any additional clinical breast exams over and above the annual Pap/pelvic/breast exam which are deemed clinically necessary with the appropriate problem-oriented E/M service code and diagnosis codes to indicate the Medical conditions or symptoms involved.


 HCPCS code Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) describes the services necessary to procure and transport a pap smear specimen to the laboratory. If an evaluation and management (E&M) service is performed at the same patient encounter solely for the purpose of performing a screening pap smear, the E&M service is not separately reportable. However, if a significant, separately identifiable E&M service is performed to evaluate other medical problems, both the screening pap smear and the E&M service may be reported separately. Modifier 25 should be appended to the E&M CPT code indicating that a significant, separately identifiable E&M service was rendered.”


POLICY 

The Health Plan considers certain screening services to be a component of preventive medicine services or annual GYN examinations.1 When reported with problem oriented E/M services, the screening service should be considered when determining the appropriate level of E/M services to report. Therefore, a screening service reported on the same date of service with preventive medicine ervices, annual GYN examinations, and/or problem oriented E/M are not eligible for separate reimbursement even when reported with modifiers -25 or -59. (See also our Bundled Services and Supplies and Modifier 59 reimbursement policies.)

For the purpose of this policy, screening services include:

• G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination

• G0102 Prostate cancer screening; digital rectal examination

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



CODE                 RULE        CODE

G0123

Incidental

88141


Raionale for Edit:

Anthem Central Region bundles G0123, G0143, G0144, G0145, G0148 and P3000 as incidental with 88141, 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175. Based on the National Correct Coding Edits, codes G0123, G0143, G0144, G0145, G0148 and P3000 are listed as component codes to codes 88141, 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175. Therefore, if G0123, G0143, G0144, G0145, G0148 and P3000 is submitted with 88141 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175--only 88141 88142, 88143, 88147, 88148, 88152, 88153, 88154, 88164, 88165, 88167, 88174 and 88175 reimburses.


Anthem Central Region bundles G0124 as incidental with 88141. Based on the National Correct Coding Edits, code G0124 is listed as a component code to code 88141. Therefore, if G0124 is submitted with 88141-- only 88141 reimburses.

Anthem Central Region bundles 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166,  88167, 88174, 88175, G0147, G0148, P3000 or P3001with G0124. Based on the National Correct Coding Edits, codes 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0147, G0148, P3000 or P3001 are listed as component codes to code G0124. Therefore, if 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0147, G0148, P3000 or P3001 is submitted with G0124--only G0124 reimburses.


Well woman Exam POLICY

Well Woman Exams do not require prior authorization.

Advantage

Well woman exams (G0101, Q0091, S0610, S0612) are covered when billed with a family planning diagnosis code (V25.01-V25.9). (ICD-10-CM DRAFT CODES; EFFECTIVE 10/01/2015: Z30.011, Z30.013, Z30.014, Z30.018, Z30.019, Z30.012, Z30.02, Z30.09, Z30.430, Z30.432, Z30.433, Z30.2, Z30.8, Z30.40, Z30.41, Z30.431, Z30.49, Z30.42, Z30.49, Z30.8, Z30.9)

Well woman exams are considered a form of an evaluation and management (E/M) service and will be denied if reported with other E/M procedure codes for the same date of service.

Modifier –SA may be used to indicate that a nurse practitioner rendered the service in collaboration with a physician

Modifier –SB may be used to indicate that a nurse midwife provided the service
Elite  Deductible and Copayment/Coinsurance waived (when billed with appropriate diagnosis code):

* Screening Pap Tests (G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091)

* Screening Pelvic Examinations (G0101)



CODING/BILLING INFORMATION

The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

HCPCS CODES

G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination

G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

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