Woman charged extra for asking doctor too many questions Saturday, Aug 8 2009 

Woman charged extra for asking doctor too many questions | 3 ON YOUR SIDE |
Arizona | azfamily.com

by Gary Harper/3 On Your Side

August 5, 2009

A Valley woman says she has a billing problem with her doctor’s office.

The billing problem has to do with a “well woman exam,” basically it is an annual physical for women.

The woman you are about to meet says it was supposed to be covered 100% by her insurance carrier, so why does she keep getting billed by the doctor’s office?

Shannon Karal, like a lot of women, knows the importance of having an annual physical. She says, “I do all my preventative visits for dentist, doctor, any of the normal things I try to go as much as they say you should go.”

So Shannon scheduled a well woman exam at a physician’s office called Doctors Goodman and Partridge, an exam she says that is 100% covered by her insurance carrier. Shannon explains, “I just had some questions and concerns about normal things that a young woman like me would have.”

Shannon says the exam was completely paid for by her insurance, however, she keeps getting a bill for $92 from the doctor’s office so, she called to find out why and, according to Shannon, she was told she asked too many questions during her exam.

She admits, “It makes me feel like next time I go to the doctor I shouldn’t share any of my questions or concerns or take any more time out of their day because I might be charged extra for that.”

Shannon maintains the questions she asked during her exam were all normal “female-related” questions and she cannot believe she would be charged. “I would completely understand this extra charge if there was another test done or something they do for my questions. But nothing! It was all verbal.”

The office of Doctors Goodman and Partridge would not talk to 3 On Your Side about Shannon’s case citing privacy issues but after our inquiry, they sent Shannon a letter saying, “The problems evaluated and managed at that visit were above and beyond the scope of a normal well woman exam” but, Shannon says that is nonsense and feels she is being billed for asking too many female-related questions, and taking up too much of the doctor’s time. Shannon tells 3TV, “I feel like there’s a stop watch every time I go to the doctor and they’re gonna be timing me and making sure I don’t go over that time and if I do then ‘Oh, there might be an additional charge for this.'”

High-Risk Screening Paps for Medicare Monday, Apr 27 2009 

Q0091 is for “obtaining the screening Pap”.  If you are doing a woman’s annual “high-risk” pap, you can use this code to obtain it.   If it were a diagnostic pap, this code would not apply.  And, if the physician is NOT doing the pelvic exam (G0101) annually for a high-risk patient, he is throwing money out the window, IMHO.

Medicare allows for a pelvic exam and screening pap every two years; however, if the patient is “high-risk” they are allowed to get a screening pap every 12 months. High-Risk Factors are:

Cervical Cancer High Risk Factors

* Early onset of sexual activity (under 16 years of age)
* Multiple sexual partners (five or more in a lifetime)
* Sexual partners who have multiple sexual partners
* History of a sexually transmitted disease (including HIV infection)
* Fewer than three negative Pap tests within the previous seven years

Vaginal Cancer High Risk Factors

* DES – exposed daughters of women who received DES during pregnancy
* Women (under age 65) who have not had a Pap test in 5 years or more.

High Risk Diagnosis Code= V15.89

Well-Woman Coding Wednesday, Apr 22 2009 

Starting January 1, 2009, BCBS will not be reimbursing G0101, Q0091 or the S0610-2 codes when done with the preventive medicine visit. We have now changed our policy that we will not perform the well-woman visit on the same day as the preventive medicine visit in response to a few of the insurance companies’ new policies. Here’s my response to Physicians Practice on this, it’s not short, but this is my view…

2) ASK THE EXPERTS: Two for the price of one?

QUESTION: Concerning billing for pelvic exams and Pap smears, are they nonbillable services that the physician must just increase his E&M charge to cover? ANSWER: Medicare covers both, with certain limitations. The frequency is determined by risk. To bill Medicare, use a screening diagnosis code, usually v76.2 or v76.47. The procedure is billed with HCPCS codes. Usually, other payers do consider a Pap to be part of a preventive exam — and so also part of the E&M code. There are some payers in the country who will pay separately for the collection of the Pap smear when performed during a routine preventive exam. Usually they provide written instructions to bill the Q0091 as an additional code. If the payer has issued that instruction, report the code. — Pamela Moore, PhD

Dear Editor: Regarding the answer provided to the “Ask the Experts” question, there are options for billing pelvic exams and Pap smears for non-Medicare payers, albeit inconsistently by health plan. Some health plans will pay G0101, Q0091, S0610 and/or S0612. Some will pay one or another, some will pay a combination of two, others will pay certain ones with a preventive visit (9938x-9939x series) and others will not. Some will only pay the HCPCS codes above with an Office Visit (9920x-9921x series) and others will not. Usually health plans are not forthright in communicating their reimbursement patterns and the provider will need to do their own research and billing trials based on health plan.

Billing the Q0091 and/or the G0101 with a Preventive Medicine code is somewhat controversial. You will find some people who are adamantly against it. I personally feel that because the Preventive Medicine codes are only differentiated by New and Established patient and by Age; therefore gender specific further evaluation should be reimbursed on top of the Preventive Medicine visit. So, basically, a female preventive medicine exam reimburses the same exact amount as a male of the same age. However, a well-woman exam is more labor intensive, greater risk and utilizes more supplies and time than what would be included in a well-man exam. Why shouldn’t we receive a higher reimbursement to cover the costs of a breast and pelvic exam and obtaining pap smear? We may not have to pay for the thin-prep containers, but we do have to pay for the speculum, spatulas, brush, gloves, lubricant, gown, etc.

In addition, many women choose to see their PCP for the general physical exam and go to their gynecologist for the well-woman part of it. Should the gynecologist use the Preventive Medicine code for their portion of the exam….even though they don’t go beyond the genitourinary system? The gynecologist should be able to code the G0101 and the Q0091 (and possibly an OV code if there is a problem-oriented issue discussed), leaving the Preventive Medicine code to the PCP. Now, what happens if the health plan will never pay the Q0091 and G0101? The gynecologist will not get paid!

I typically suggest that the Q0091 and G0101 code be coded to every health plan and not to worry which ones pay and which ones don’t. It’s better to code it and get paid for one or both than to not code and not get paid on either. For example, for United Healthcare, I recommend that our physicians perform and code a Preventive Medicine code first. During that visit, the physician should perform the basic preventive medicine exam and order the blood work and any other testing that is necessary for age and gender. Have the patient return to the office on another day and go over the results of the testing that has already been done, address any problem issues, and then do a well-woman exam…code the OV(with modifier -25) and the G0101 and Q0091 codes for that second visit. I understand that it is inconvenient for the patient and we try to make things convenient; but this is what the health plans require. I have actually had a particular health plan state that this is the way we should code, regardless of it being inconvenient to the patient. It’s too bad, but physicians have to start looking at their bottom line!

I definitely advise people to look into the S0610 and S0612 for the gynecology visit, especially with BCBS. They will find the reimbursement rates are very good. Other health plans will reimburse the S-codes; however, Medicare will not. We are currently testing variations of coding combinations by payer to determine which is the most appropriate combination to bill by payer. This does take a lot of time on your staffs part, but it could be very cost effective if you are able to actually receive reimbursement for the services you are providing. When using the S0610/S0612, do not use the G0101 code, because they are pretty much the same code. However, I would code Q0091 in addition to the S-code if a screening pap smear was obtained.

These codes are controversial in the “coding” community; however, I firmly believe that there should be increased reimbursement for the well woman preventive exam. It truly troubles me that the Preventive Medicine codes are reimbursed the same for male and female patients. We have already established that it requires more time, more risk and requires supplies to perform the breast, pelvic and pap. The fact that some health plans want to bundle that into the Preventive Medicine exam is ridiculous! One of my goals is to inform more physicians about this and, eventually, the more physicians who take a stand, the more power we have to change the reimbursement by the health plans!

There are many physicians, billers and coders, who just accept whatever they can get as far as reimbursement. There is not enough time in a day to do appeals and really learn the various coding policies. One of the worst mistakes a physician can do is to under staff the billing department and/or not have billing people who have the means (resources) to stay abreast of all the inconsistencies in billing. The other problem that I see in our industry is that, coders especially, see only in “black and white”. There is no “outside the box” for them. This is a detriment because, as we can see, the health plans do not know “black and white”. Each health plan develops their own reimbursement policies that go against what coders learn. There are Medicare guidelines, CPT guidelines, BCBS guidelines, UHC guidelines…I think you get the picture! When I talk with my physicians and billing/coding staff, I will clarify that I am referring to one guideline versus another.

Now, until all physicians, coders and billers can get on the same page and insist that the health plans reimburse for the services that the physicians perform, we are going nowhere and the health plans are holding the cards! I applaud physicians and their staff for seeking information and building their understanding of this part of the industry.

Thank you for allowing me to present by opinion on this subject.