Coding and Billing Guidelines for Gynecological and Rectal Exams

Section: Coding Billing

North Dakota Blue Cross and Blue Shield (BCBSND) has 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.

Gynecological Exam and E&M Performed on the Same Day

When a physician performs a systemic physical examination as part of an annual gynecological examination and provides an unrelated, separately identifiable E&M on the same day both services may be billed. The appropriate medical E&M office visit code (99201-99215) may be reported with modifier 25 in addition to the gynecological examination (G0101). If the reported service(s) do not meet the component requirements of the codes billed the services should not be billed.

The patient’s medical record must contain:

  • Sufficient documentation regarding the appropriateness of performing both services
  • Documentation the key components of the services were met.

Preventive E&M and Gynecological Exam Performed on the Same Day

When a physician performs an annual gynecological 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 only report the Preventive E&M when rendering a gynecological and systemic preventive annual E&M service.

Preventive E&M or Gynecological Exam and Pap Smear specimen collection Performed on the Same Day

When a physician performs a Pap Smear (obtaining the specimen, preparing the slide, and conveyance - Q0091)  on the same day as a gynecological examination (G0101) or preventive E&M (9938X or 9939X) providers 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 (obtaining the specimen, preparing the slide, and conveyance - Q0091) and an unrelated, separately identifiable E&M on the same day both services may be billed. The appropriate medical E&M office visit code (99201-99215) may be reported with modifier 25 in addition to Q0091. If the reported service(s) do not meet the component requirements of the codes billed the services should not be billed.

The patient’s medical record must contain:

  • Sufficient documentation regarding the appropriateness of performing both services
  • Documentation the key components of the services were met.

Preventive E&M and Digital Rectal Examination performed on the Same Day

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

Billing Scenarios

  • Annual Gynecological Examination with Pap Smear
  • Provider completes a significant unrelated E&M
  • Annual Preventive Examination
  • Pelvic and breast examination
  • Screening Pap smear collection
  • Annual Preventive Examination
  • Prostate cancer screening; digital rectal examination

Codes

  • Report appropriate E&M Office (99201-99215) with Modifier 25
  • Report G0101

Note: When the 25 modifier is reported, the patient’s records must clearly document separately identifiable medical care was rendered.

  • Report appropriate Preventive E&M (9938X or 9939X)
  • *Do not report G0101 or Q0091
  • Report appropriate Preventive E&M (9938X or 9939X)
  • *Do not report G0102

BCBSND archived the NDRP-E/M-006 Gynecological and Rectal Reimbursement Policy effective March 1, 2020 as providers must follow the Correct Coding Guidelines Policy regarding appropriate billing for services.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference:

Correct Coding Guidelines