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Family Practice Coding Alert

Reader Questions:

UHC's Screening Edit Recall Doesn't Spell Payment

Question: A family physician performed a well-woman exam and treated the patient for pink eye. We submitted the claim as 99212-25, 99397, Q0091 and G0101.

UnitedHealthcare (UHC) bundled the pelvic and breast exam, as well as the Pap smear, into the office visit. Did I code the encounter correctly?

Missouri Subscriber
Answer: The problem is with the insurer, not your coding. On claims prior to June 2005, UHC considers G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) a component of an E/M service. So if you submit the screening codes in addition to 99201-99215, the payer will bundle the pelvic and breast exam and the Pap smear into the office visit.

Incidentally, even if you didn't bill the problem-related code, the insurer would still deny G0101 payment. UHC includes G0101 in Q0091.

UHC, however, is changing its Laboratory Rebundling Policy. But that still doesn't mean you'd receive payment for G0101 and Q0091 during a well-woman check and sick visit. Starting June 2005, UHC will include the screening codes in the preventive medicine service, according to UnitedHealthcare's Preventive Medicine Policy.

The insurer's new bundling edit is consistent with CPT. CMS created G0101 and Q0091 to facilitate congressionally mandated coverage of two elements of an otherwise statutorily excluded service (the preventive medicine visit). Preventive medicine visits (e.g., 99387, Initial comprehensive preventive medicine evaluation and management  ...; 99397, Periodic comprehensive preventive medicine ...) include an "age- and gender-appropriate history/exam," Most FPs would agree that such an exam for a well-woman would include a pelvic and clinical breast exam as anticipated by G0101.

Likewise, CPT does not have a separate code for collection of a Pap specimen, either screening or diagnostic. CPT takes the view that such specimen collection is part of the E/M, as does United.