Forum - Questions & Answers

Apr 23rd, 2015 - envision 1 

Medicare Claim Denial for Pap Smear

I became Medicare-eligible April 1, 2014 (last year). Within the first 2 weeks, I had my preventive exam, pelvic and pap smear from a doctor who accepts Medicare assignment in full. I was advised to do this as a new Medicare patient. I did not realize until last month that a bill for $125.84 from Quest Diagnostics was denied and never covered. (It was first denied as "applied to deductible," but this was re-determined that I had paid the deductible, and then was denied as "not covered services.") I just lost somewhere in the multiple billings, and never realized this was denied.

Date: 4/12/14
Code Used: CPT® 87621 Virus, AMP Probe $125.84
ICD-9: V72.31

I have called the doctor's office, insurance billing person, Quest Diagnostics, Medicare and my secondary, Mutual of Omaha. The doctor's insurance billing person insists the billing was done correctly, and that this was her first case of Medicare denial using the codes she uses. Quest cannot do anything because the doctor determines the billing codes. The final result = Medicare and Mutual of Omaha denied the claim as "not covered services."

Even the Medicare.gov website says:
You pay nothing for the lab Pap test, nothing for the Pap test specimen collection and nothing for the pelvic exam, if the doctor accepts assignment.

I have been advised by Medicare, Quest and Mutual of Omaha to have the doctor's office re-bill correctly. However, the insurance biller ascertains that she DID bill correctly.

What are the PROPER codes for a first-time 65-year-old female Medicare patient who is having a PREVENTIVE SCREENING, PAP SMEAR + PELVIC EXAM on April 12, 2014? If someone can advise me, and help me a definitive written source for the insurance biller, I would appreciate it.

Thank you VERY much.

Apr 23rd, 2015 - Charlene   50 

re: Medicare Claim Denial for Pap Smear

This information is available through CMS' Medicare Learning Network:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN907791.html?DLPage=1&DLFilter=preventive&DLSort=0&DLSortDir=ascending

It sounds like the office has not coded the claim correctly. Provide your doctor's office with this information.

Apr 23rd, 2015 - envision 1 

re: Medicare Claim Denial for Pap Smear

Thank you so much, Charlene! I will share this info right now.

Apr 24th, 2015 -

re: Medicare Claim Denial for Pap Smear

Hi, first of all I just want to say that code 87621 is a deleted code, so your provider is incorrect for billing that code and could be why its being denied and applied to your deductible. I work for an OB-GYN practice as their coder and the way we were told to bill MCR for Well Woman Exams is as such:

Well Woman Exam =G0101 w/DX V76.2
Pap =Q0091 W/DX V76.2
Urnine =81002 w/DX V72.62

unless the patient has been deemed high risk by the provider than we use code V15.89 on the pap and the exam. Per MCR guidelines patient is only allowed a Well Woman exam every two years unless deemed high risk, than they may come in every year. I have been billing all of our MCR patients like this and have had no issues w/denials. Good Luck and coodo's to you for checking it out:)

Apr 24th, 2015 - Kat31477 56 

re: Medicare Claim Denial for Pap Smear

If you are only billing the G0101 / Q0091, yet performing a full physical exam for patients - then your providers are short changing themselves. You can bill the physical as non-covered, carve out the covered portions of the G and Q from the charge amount, and bill the patient / secondary the balance. G0101 covers the pelvic / breast exam, but not the other components included in the physical. Medicare has addressed this numerous times in guidance and informational booklets for beneficiaries.

Apr 24th, 2015 -

re: Medicare Claim Denial for Pap Smear

I know and thanks as I have brought that to their attention, but the billing manager wants it billed out that way to elimanate denials, so the provider does the full exam knowing we are only going to bill for the just the pelvic and breast:)



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