Applies to:

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:

New patients	99381-99387
Established patients	99391-99397

Criteria for reporting G0101, pelvic and breast exam

• Inspection/palpation of breasts
• Perform and document 6 out of these 10 elements:
  1. Digital rectal exam and pelvic exam (with or without specimen collection)
  2. External genitalia exam
  3. Urethra meatus exam
  4. Urethra exam
  5. Bladder
  6. Vagina
  7. Cervix
  8. Uterus
  9. Adnexa/parametria
  10. 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.

99459

The practice expense relative value unit (RVU) of existing Evaluation and Management (E/M) codes, including preventive services codes, accounts for clinical staff time. It's not consistent with RVU pricing to separate the staff time spent chaperoning a pelvic exam from other staff time included in E/M services. Therefore, this code isn't separately payable in addition to existing E & M codes. Priority Health follows coverage decisions of CMS and MDHHS for those products.