Payment will be made for one (1) annual gynecological examination (G0101, S0610, or S0612) regardless of the patient's condition, and one (1) routine pap smear (G0123, G0124, G0143-G0145, P3000, P3001) per calendar year for all females.

A gynecological exam (code G0101, S0610, or S0612) may include, but is not limited to, the following services: history, blood pressure and/or weight checks, physical examination of pelvis/genitalia, rectum, thyroid, breasts, axillae, abdomen, lymph nodes, heart and lungs.

When a physician performs a systemic physical examination which includes an annual gynecological examination, a medically-focused condition may be encountered. In some instances, treatment for a medically-focused condition may require more extensive medical evaluation, treatment and management. This treatment may result in significant additional work requiring the key components associated with a problem-oriented evaluation and management (E/M) service. In these cases, the appropriate medical E/M code (99201-99215, 99381-99397) may be reported in addition to the gynecological examination (G0101, S0610, or S0612).

Reporting of more than one visit per day should not be a common occurrence in any practice. To justify these services, the patient’s records must contain sufficient documentation regarding the appropriateness of performing both services, and documentation that the key components of the E/M service have been met. If the reported E/M service does not meet the component requirements, the second service will not be eligible for reimbursement. Payment for the E/M service will also be subject to coverage limitations specified within the individual member’s contract.

Obtaining the specimen, preparing the slide, and conveyance of a pap smear (Q0091) is considered to be an integral part of the gynecological examination (G0101, S0610, or S0612) or evaluation and management service (99201-99215, 99381-99397). It is not eligible as a distinct and separate service. Therefore, any payment for the gynecological exam or evaluation and management service on the same date of service includes the allowance for this procedure. A participating, preferred, or network provider cannot bill the patient separately for this service in this case. Charges for obtaining the specimen, preparing the slide, and conveyance of the pap smear (Q0091) when reported independently of the gynecological examination, or evaluation and management service, are not eligible for payment. A participating, preferred, or network provider cannot bill the patient for the denied service.

Note:See Medical Policy Bulletin L-1 for additional information regarding pap smears.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

FEP claims for multiple office visits submitted on the same date of service by the same physician will not be reimbursed except when the patient actually has two separate visits on the same day. Effective January 1, 2002, if the office/outpatient visit is reported with a 25 modifier, then FEP benefits should be approved for both the preventive service and the medical service. The member should not be liable for more than one copay. When a patient is scheduled for a routine annual examination, but at the time of the visit is diagnosed with a medical illness or disease, and two office charges are submitted for the same visit, payment will be provided for the annual gynecological examination if the patient has not had one within the past year. The visit charge with the medical diagnosis will then be denied as a duplicate charge. If the annual gynecological examination benefit has been used within the past year, the visit will be paid as a covered service under Other Medical and the routine visit charge will be denied as not covered.

PRN References

04/1995, Annual gynecological exams and routine pap smears, reporting of,
02/2002, Blue Shield considers Q0091 integral part of an exam