Getting New Patient Office Visits Paid by Medicare

If a new patient presents in your office and it is determined through evaluation that a pap smear is necessary – Medicare will probably deny the claim unless you can show medical necessity of the preventative measure.

You will need to use pap and a pelvic code with 99203 is if the patient presents with a problem that needs to be evaluated. Using code 99203 (Office visit) is not a substitute for the rest of a preventive exam (which Medicare generally does not cover). Use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the code you are submitting on your medical billing and you will have a greater chance of getting a reimbursement for your medical billing claim.

If this is a Medicare patient, you can consider using G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the pelvic/breast exam. Although Medicare does not generally cover preventative measures, necessary exams usually are. Such as G0101 for the pelvic and breast exam and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the collection of the Pap specimen in the year Medicare covers it.

Make a note that using the G codes in your medical billing does not include taking history or counseling, they only refer to the physical exam and those elements Medicare rules describe.

View all Articles by: Melissa C. - OMG, LLC. CEO