Medical Billing Dilemma – Break Out Services for Medicare

Did you know that you might be missing a full reimbursement for well-woman care if you’re not breaking out the breast exam and pap smear? If the medical billing claim is for a well woman exam; in almost every instance, Medicare will allow you to break out the claims and get reimbursement for both services.

If the physician provides a complete well-woman exam for a Medicare patient, you should report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the breast and pelvic exams. When the physician also obtains a Pap smear, use Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory)and this will enable your practice to realize a reimbursement for both services.

Just make sure that you have the necessary medical necessity and documentation to back up the breaking out of both services and in most cases you must attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). An important thing to remember, for Medicare patients at normal risk, you can report a Pap smear only once every two years. The diagnoses your physician will use in these cases include V72.31 (Routine gynecological examination), V76.2 (Special screening for malignant neoplasms; cervix) and V76.47 (… other sites; vagina),

Using these techniques, you should be able to increase your Medicare coverage of this common service to your medical billing claims.

View all Articles by: Kathryn E, CCS-P - Retired