Highmark Medical Policy Bulletin |
Section: | Visits |
Number: | V-35 |
Topic: | Annual Gynecological Examinations and Routine Pap Smears |
Effective Date: | March 24, 2003 |
Issued Date: | March 24, 2003 |
Date Last Reviewed: | 11/2001 |
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-G0145, G0141-G0148, 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. |
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99201 | 99202 | 99203 | 99204 | 99205 | 99211 |
99212 | 99213 | 99214 | 99215 | 99381 | 99382 |
99383 | 99384 | 99385 | 99386 | 99387 | 99391 |
99392 | 99393 | 99394 | 99395 | 99396 | 99397 |
G0101 | G0123 | G0124 | G0141 | G0143 | G0144 |
G0145 | G0147 | G0148 | P3000 | P3001 | Q0091 |
S0610 | S0612 |
Traditional (UCR/Fee Schedule) Guidelines
Prior to January 1, 2002, FEP claims for multiple 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, FEP benefits should be approved for both the preventive service and the medical service, if it is determined that the patient's condition required a significant, separately identifiable service above and beyond the routine service provided. |
Comprehensive/Wraparound/PPO Guidelines
Managed Care (HMO/POS) Guidelines
PRN References |
[Version 005 of V-35] |
[Version 004 of V-35] |
[Version 003 of V-35] |
[Version 002 of V-35] |
[Version 001 of V-35] |
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