Getting Paid for Women's Health Services in Primary Care

By Dowling, Renee | Medical Economics, February 10, 2015 | Go to article overview

Getting Paid for Women's Health Services in Primary Care


Dowling, Renee, Medical Economics


Q I work for a family medicine practice, and we have women, usually not Medicare patients, come in frequently for their pap and pelvic. Unfortunately; we don't know if they've had another preventive exam in the last year or if the patient wants her OB/GYN to perform the exams. How do we bill for these situations?

A: THIS HAPPENS

frequently in primary care practices: The patient sees her primary care physician (PCP) or family physician for her annual physical exam. However, she wants her pap and pelvic exam performed by her OB/GYN ora female physician.

Women's preventive health has always been an issue because insurance carriers usually pay for only one preventive service in a calendar year.

When a patient comes in for her annual physical exam and she is not covered by Medicare, you need to ask her if she plans to have the annual exam with pap, pelvic and breast exam. If the answer is yes, then the physician would perform it and choose the preventive code based on the patient's age and whether she is a new or established patient.

If the patient decides she wants her pap and pelvic performed by her OB/GYN, this is when the conversation should begin regarding what service the PCP will perform and billing for.

Here are a few examples:

EXAMPLE 1:

Patient comes in for her annual preventive exam with pap and pelvic but is menstruating today so she wants to wait until next week for the pap and pelvic. How do you bill for this?

ANSWER:

Bill the appropriate 9938x or 9939x code once, which will cover both visits. You would bill this only once even though the patient had a second visit because you have already been paid for the service; it just wasn't completed until the following week.

EXAMPLE 2:

A patient comes in for her annual preventive exam, but wants to see her OB/GYN for her pap and pelvic. How do you bill for this?

ANSWER:

You can bill the appropriate 9938x or 9939x code and the visit may be paid; however, insurance carriers usually do not pay for a second preventive service, in which case the patient may be responsible for payment. The American Congress of Obstetricians and Gynecologists "Frequently Asked Questions," 5th edition, states that the patient should be aware of a charge and the patient may be responsible if the only code available is a preventive code. …

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