Forum - Questions & Answers

Jul 30th, 2015 - Sizemorec

Pap smear

When coding the office visit for a routine Pap smear exam, the use of 99397-GY is used along with Q0091-GA and G0101-GA. MEDICARE DENIES THE 99397-GY Established patient periodic preventative medicine examination age 65 and older. Could the code 99203-25 for New patient office or other outpatient visit, typically 30 minutes be used and is it covered by Medicare for this purpose. Many patients have complained about these denials.

Jul 30th, 2015 - Kat31477 56 

re: Pap smear

99203-25 could be used and would be covered, provided your dx code is a 'problem' diagnosis and the documentation supports the patient presenting with a complaint. Typically, during this routine visit it is just that - routine physical - which is a non-covered service by Medicare. Yes, the patients complain, but if that is what is being done then it is the correct way to bill. That being said, you should be 'carving out' the amount that Medicare pays for the Q0091 and G0101 from the charge for the 99397 - meaning it is a reduced fee for medicare patients vs. what you would charge for that code to a commercial insurance. CMS has a number of excellent references on their website regarding this topic, including a wonderful pie chart that illustrates the 99397 and the pieces of the pie that Medicare covers (Q0091 and G0101) vs. the rest which is a non-covered service. When I worked GYN, I would provide patients with a copy of this chart to aid in their understanding of why they had a non-covered balance due. More and more supplemental and secondary plans cover the non-covered balance, too, so make sure these are being submitted correctly to the secondaries.

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