High Risk Factors for Medicare Well Women Exams

Coding along with reimbursement for Medicare well-woman screening exams is certainly one of the major challenges in ob/gyn medical coding. You should know whether a patient meets Medicare’s criteria for “high-risk” or “low-risk.” This risk factor controls the regularity with which Medicare pays for well-woman care. Also, know what ICD-9 codes are applicable to this scenario.

Medicare sets parameters regarding when a patient is high-risk as well as worthy for annual well-woman exams, against when a patient is low-risk and eligible for well-woman exams simply once every two years. Even though the codes for the exam and also Pap smear collection are similar – G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) – determining patient risk is crucial to proper reimbursement and accountable preventive care.

Risk Codes plus Factors

While billing for Medicare well-woman care, you must use one of three ICD-9 codes:

  • V76.2 – (special screening for malignant neoplasms; cervix)
  • V76.49 – (special screening for malignant neoplasms; other sites)
  • V15.89 – (other specified personal history presenting hazards to health; other)

The ICD9 Codes V76.2 and V76.49, selected by Medicare for when the patient no longer has a uterus, are the “low-risk” codes, besides V15.89 is the “high-risk” code. As far as well-woman exam is concerned, high-risk indicates that because of family, personal/social or medical history the patient is then at higher risk for developing cervical or further gynecological cancers. It has no bearing on any other health problems the patient may have that are unconnected to her reproductive and sexual history.

There are very precise parameters that permit you to be high-risk and thus receive screening (not diagnostic) Paps, screening pelvic as well as breast exams every year paid by Medicare. Medicare rules have numerous factors that specify high risk:

  • V69.2 (high-risk sexual behaviour, Onset of sexual activity under 16 years of age)
  • V69.2 (Five or more sexual partners in a lifetime)
  • V13.8 (personal history of other specified diseases: History of sexually transmitted disease)
  • 795.0 (abnormal Pap smear : Absence of three negative Pap smears)
  • V08 (asymptomatic HIV status, or 042, HIV : History of HIV)
  • Absence of any Pap smears in the previous seven years. No exact ICD-9 codes, occurs for this, but V15.89 may be adequate by itself. You may require to submit documentation with the claim
  • 760.76 (DES affecting fetus via placenta or breast milk : Prenatal exposure to DES, commonly referred to as DES daughter).

These criteria are applicable to women who are no more of childbearing age. The risk status is determined mainly through the interview form the patient completes at the beginning of her treatment with the physician.

Resting on the risk status, the encounter with the patient is billed to Medicare as following:

  • G0101 (linked to V76.2/V76.49 or V15.89) or
  • Q0091 (linked to V76.2/V76.49 or V15.89)