This document is being archived effective December 1, 2024. This document provides coding and billing guidelines for Gynecological & Rectal Exams.
Coding & Billing Guidelines
Blue Cross Blue Shield of North Dakota (BCBSND) identified an increase in providers unbundling Preventive Evaluation and Management (E/M) and/or Gynecological Screening services. The claims reviewed include additional service which are inherent components of the codes such as pap smear collection or digital rectal examinations. The below billing guidelines are provided to educate providers on correct billing.
E/M Service & Gynecological Exam
When a practitioner performs a cervical or vaginal cancer screening, including pelvic and clinical breast (G0101) examination, and provides an unrelated, separately identifiable E/M (99202 – 99215) on the same day both services and the pelvic examination add-on code (99459) may be billed. If the reported service(s) do not meet the component requirements of the codes billed, the services should not be billed.
Preventive E/M & Gynecological Exam
When a practitioner performs a cervical or vaginal cancer screening, including pelvic and clinical breast examination (G0101) and a preventive examination (9938X or 9939X) on the same day, there is significant overlap of the components of these two services (i.e., history, blood pressure, weight checks, and/or system gender and age-appropriate physical examination). However, the preventive examination may include services beyond the scope of the gynecological exam, such as counseling and anticipatory guidance, risk factor intervention, age-appropriate lab work, and certain screening tests (e.g., Pap Smear). Providers should report the Preventive E/M (9938X or 9939X) and pelvic examination add-on code (99459) when rendering a cervical or vaginal cancer screening and Preventive E/M service.
Preventive E/M or Gynecological Exam & Pap Smear Collection
When a practitioner performs a Pap Smear obtaining the specimen, preparing the slide, and conveyance - Q0091) on the same day as a cervical or vaginal cancer screening, including pelvic and clinical breast examination, (G0101) or preventive E/M (9938X or 9939X), the practitioner should not report the Q0091 separately as the specimen collection is an inherent component of G0101, 9938X, and 9939X.
If a physician performs a Pap Smear (Q0091) and an unrelated, separately identifiable E/M (99202-99215) on the same day both services and the pelvic examination add-on code (99459) may be billed.
Preventive E/M & Digital Rectal Examination
Prostate cancer screening, digital rectal examinations (G0102) is considered an inherent component of both a problem focused E/M and Preventive E/M service. Separate reimbursement will not be made for G0102 when billed on the same date of service by the same performing provider billing an E/M.
Gynecological and Rectal Exams Billing Examples
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Billing Scenarios
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Coding
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- Preventive E/M with cervical or vaginal cancer screening, including pelvic and clinical breast examination
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- Report appropriate Preventive E/M (9938X or 9939X)
- Report Pelvic exam Add-on (99459)
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- Annual Gynecological Examination with Pap Smear
- Provider completes a significant unrelated E/M
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- Report appropriate E/M Office (99202-99215)
- Report G0101
- Report Pelvic exam Add-on (99459)
Note: When the 25 modifier is reported, the patient’s records must clearly document separately identifiable medical care was rendered.
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- Cervical or vaginal cancer screening, including pelvic and clinical breast examination
- No separately identifiable E/M
- Screening Pap smear collection
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- Report G0101
- Report Pelvic exam Add-on (99459)
Note: Do not report E/M as it was not separately identifiable.
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- Annual Preventive Examination
- Prostate cancer screening; digital rectal examination
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- Report appropriate Preventive E/M (9938X or 9939X)
Note: Do not report G0102
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