Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: V-35-018
Topic: Annual Gynecological Examinations
Section: Visits
Effective Date: August 1, 2012
Issue Date: September 23, 2013
Last Reviewed: September 2013

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.

The criteria above does not apply to those groups that follow the Women’s Health Federal Mandate offered, issued or renewed on or after August 1, 2012.

When reported, payment may be made for the physician interpretation (G0124, G0141, P3001) in addition to the pap smear codes (G0123, G0143, G0144, G0145, G0147, G0148, P3000).

Gynecological Exam and E&M, Same Day
When a physician performs a systemic physical examination as part of 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) 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.

Gynecological Exam and Preventive Exam, Same Day
When a physician performs an annual gynecological exam and a preventive exam  (99381-99397) on the same day, there is significant overlap of the components of these two services (e.g., history, blood pressure and/or weight checks, physical examination). However, the preventive exam 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.

Reporting of both services per day should be a rare occurrence in any practice. To justify these services, the patient's records must contain sufficient documentation that the components of both services were met.  Payment for the preventive visit will also be subject to coverage limitations within the individual member's contract.

Pap Smear
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.

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.

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.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.


The policy position applies to all commercial lines of business


Denial Statements

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

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U.S. Department of Health and Human Services
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Room 509F, HHH Building
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1-800-368-1019, 800-537-7697 (TDD)

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