Billing & claim for Preventive Care for Women

I am seeking expert opinion.

I have some issues with my health insurance bill & claim from my provider and BlueShield. So I am just doing research online and came across your site.

My wife went to see her PCP for a Preventive Care. Doctor did Pep smear and ordered some lab test. She assured that those were for Preventive Care and should be covered.

Her benefit for preventive Care is as follows:

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Prior Authorization: Not Required

Preferred Provider
Amount or percentage you pay for this service ("copay") $0.00 Per Visit
Does your payment count toward satisfying your deductible? No


Preventive Health Services

Annual routine gynecological office visit - This includes gynecological examination, office visit, routine mammography, routine Papanicolaou (Pap) test or other FDA approved cervical cancer screening test, human papillomavirus (HPV) screening tests.

Annual routine physical examination office visit - This includes the physical examination office visit, routine eye/ear screening for insureds through age 18 and pediatric and adult immunizations and the immunization agent. Preventive care is allowed as stipulated by the US preventive services task force, advisory committee on immunization practices and center for disease control and prevention recommendations.
Routine laboratory services - Includes well baby laboratory services.

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But when we checked claim on BlueShield site, saying we have to pay copay for office visit.

We contacted BlueShield and they said claim and processing were correct and suggesting to contact provider.

I think Doctor office submit claim with incorrect code for office visit. ( Instead of using Preventive office visit code, they may use regular visit code).

I am not familiar with coding system.

Could you please tell me whether there is special code for preventive office visit?

We also have to pay some of the lab tests performed.

I also find BCBS matter mentioned in "Well Woman Exam Coding" article by Charlene Burgett for a gyne visit.

Does she has to go to PCP for regular visit and pep smear to gyne doctor?

Thanks for your time.

re: Billing & claim for Preventive Care for Women

I don't think you will get an accurate answer without looking at your wife's chart notes. If she had a medical problem that was discussed or even family planning issues, that could result in an office visit code. However, the office may be mistaken and coded an office visit in error as well.

If you look in the Preventive Medicine section of the CPT® book, you will see that an Evaluation and Management code (9920x-9921x) code with a modifier -25 is appropriate to code with a Preventive Medicine visit (9938x-9939x) when there is a separately identifiable medical issue dealt with during the Preventive Medicine visit.

So, bottom line, yes it is possible to have an Office visit on the same day as the Preventive Medicine visit; however, it is not possible to determine if an office visit was applicable in your wife's situation.

Charlene Endre-Burgett, MS, CMA (AAMA), CPM-MCS, CPC, CMSCS
Administrator, North Scottsdale Family Medicine
Blog: www.charleneburgett.wordpress.com
LinkedIn: www.linkedin.com/in/charleneburgett