Payment will be made for one (1) annual gynecological examination (G0101, S0610, S0612, or S0613) regardless of the patient's condition, and one (1) routine pap smear (G0123-G0145, G0141-G0148, P3000, P3001) per calendar year for all females.

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, S0612, or S0613).

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.

When a pap smear (obtaining the specimen, preparing the slide, and conveyance - Q0091) is reported on the same day as a gynecological examination (G0101, S0610, S0612, or S0613),  or evaluation and management service (99201-99215, 99381-99397), and the charges are itemized, combine the charges and pay only the gynecological examination or evaluation and management service. Payment for the gynecological examination or evaluation and management service performed on the same date of service includes the allowance for the pap smear. A pap smear is not eligible as a distinct and separate service. A participating, preferred, or network provider cannot bill the member separately for the pap smear in this case.

If the pap smear is performed independently, process it under the appropriate code(s). 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 member for the denied service.

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the pap smear.  When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

NOTE:

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

Description

A gynecological exam (code G0101, S0610, S0612, or S0613) 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.

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.

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.

NOTE: The above variation does not apply when FEP is secondary to Medicare.

PRN References

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