Pelvic & breast exams, Pap tests
Group commercial HMO, EPO, POS and PPO plans
Individual commercial HMO, POS and PPO plans
Billing HCPCS codes vs. preventive service codes
Priority Health may reimburse providers for HCPCS codes G0101 and Q0091 when only specific components of the preventive service are performed. In this case, bill the HCPCS codes in place of these preventive service codes:
Criteria for reporting G0101, pelvic and breast exam
- Inspection/palpation of breasts
- Perform and document 6 out of these 10 elements:
- Digital rectal exam and pelvic exam (with or without specimen collection)
- External genitalia exam
- Urethra meatus exam
- Urethra exam
- Anus and perineum
Criteria for reporting Q0091, pap smear
- Obtaining, preparing and transfer of cervical or vaginal smear to lab
Billing well-woman services with problem-oriented E&M services
At times, providers may perform well-woman services in addition to a problem-oriented E&M service. If Q0091 and G0101 are reported solely for the purpose of an unrelated screening service, they may be separately reimbursed in addition to the problem-oriented E&M service.
- Documentation must clearly support a significant, separately identifiable service.
- Any reconsideration of denied services will require a review of medical documentation.
If the E&M service better describes the service rendered (i.e., services are not "screening" in nature but are performed to assist in diagnosing the patient's condition), then G0101 and Q0091 will not be reimbursed in addition to the E&M service (99201-99215) on the same date. Breast and pelvic exams, including obtaining, preparing, and conveying a pap smear, are considered components of an exam and medical decision-making.