Wiki - G0101 and Q0091 (2024)

Jeanie Roberts CPC

I do Ob/gyn coding and from my notes it says Q0091 is billed for doing the screening pap smear and G0101 is billed for the pelvic exam and breast check. So if both were done, you use both Q0091 and G0101 for medicare patients and you need to use diagnosis V76.2. Medicare will pay for this every two years and if the patient meets Medicare's criteria for high-risk, the exam is reimbursed every year.
Medicare preventive coverage includes a pelvic examination & breast check (G0101) and collection of Pap smear speciment (Q0091). It does not include other services normally included in a preventive exam, such as taking vital signs, examining skin, heart, lungs, and reviewing systems, past family and social history.
If more than one preventive service is provided during the same encounter, a physician should submit the screening codes to Medicare for payment (G0101/Q0091) and the preventive code 99285 etc to the patient for payment. The amount reimbursed by Medicare for the covered screening services is deducted from the amount billed to the patient for the other preventive services.
Example: annual gyn exam. Medicare covered the pap smear, pelvic exam & breast check. Doctor charges $120 for an annual exam. Dr. bills Medicare $33.68 Pelvic & breast exam and $50.58 collection of pap smear, and bills cpt 99385-52 (Preventive Med new pt) $35.74 to the patient and the Total is $120.00.

I need a little clarification for coding Medicare patients and non Medicare patients for their annual exam/pap.

Medicare pt example : 99396, G0101, Q0091

Non Medicare Patient example : 99396, 99000, Q0091.

Isn't it correct that the 99000 and Q0091 are both the handling fee?
If so, is there a different code for the G0101 for non Medicare patien't or do you bill the G0101 to the commercial insurances as you do for Medicare?

For our non-Medicare payers here in the Minneapolis area, G0101 and Q0091 are included in the preventive code. Medicare allows G0101 and Q0091 to be "carved out" and billed with the preventive visit.
http://www.wpsmedicare.com/part_b/business/carveout_services.shtml

99000 is a lab handling code and Q0091 is the pap hadling so are basically the same thing. Medicare doesn't cover 99000. They shouldn't be billed together. For non-Medicare patients you could bill 99000 but only if a venipuncture code isn't being billed also. Our payers here don't reimburse both when billed together.

If a patient comes in for just a pap/pelvic, then G0101 could be billed for the visit. Sometimes that happens when women have their physical but return on a later date for that portion.

You wouldn't need to bill with the 52 modifier because that is saying that is saying a lesser service was performed, not that you are reducing the charges. If you have a Medicare patient and carve out the G0101 and/or Q0091 and reduce the billed amount for the preventive med code, you would just bill the code as usual.

Billing for Medicare Annual Exam

I have a Medicare patient who had an annual exam on 10/6/09 and returned 11/12/10 for another annual exam. The physician also billed an e/m 99213 on the same day. She has a hx of br ca, would this be considered HR and billable to Medicare? What HR dx code can be used to indicate to Medicare this is a High Risk patient?

I did the webinar with AAPC for OB/GYN updates for 2011 and according to medicare these are some of the reasons specified for high risk and the ICD-9 to use:

-V15.89
-child bearing age:
-cervical or vagin*l CA is present
-abnormal findings in the last 3 years
-considered high-risk for developing cervical or vagin*l CA
-non child bearing age:
-onset sexual activity under 16 years of age
-5 or more sexual partners
-fewer than 3 pap smears in the last 7 years
-no pap smears in 7 years
-exposed to DES in utero

Hope this helps,
Ivonne, CPMA

I work in a OBGYN office as well. For well woman exam we bill:
G0101-GA and V76.2 code.
Q0091-GA for specimen /pap

On occcasion if the patient has a problem in same visit, the doctor will bill 99213-25.

Medicare only pays every 2 years and the patients are required to sign a waiver

Medicare GYN Exams

As of Jan 1,2011 Medicare does cover Pap Smears every year.

Breast Exam

Does anyone know what code to use if only breast exam is perform? and not the pelvic exam?

Q0091 and G0101 for commercial payers

I work for an Internist if we have a Patient who has BCBS of Mass . She comes in for an office visit billed 99213 and a pap . Can he bill both G0101 and Q0091? If not G0101 than what other code should he use? Thank you in advance!

kemasters said:

If I bill Q0091 to an insurance that does not pay for that procedure seperately can I bill the patient? I am a salaried ObGyn office where the billing is done by the hospital. The coders insist on using Q0091 for all pap claims then billing the patient when the insurance doesn't pay--even Medicaid patients.

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You are going to bill the wrong patient and they are going to have your provider up the river. You cannot bill a patient for a service that their plan covers. Correct the coding first. And who bills Medicaid patients? It appears that someone has no clue of what they are doing if they are billing patients for covered services. The EOB will state clearly that patient is not responsible. I see an audit in your future.

jouanlychen said:

does anyone know what code to use if only breast exam is perform? And not the pelvic exam?

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s0613

saoire said:

I work for an Internist if we have a Patient who has BCBS of Mass . She comes in for an office visit billed 99213 and a pap . Can he bill both G0101 and Q0091? If not G0101 than what other code should he use? Thank you in advance!

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First thing you want to do is check the carrier Medical Policy. Is your provider only submitting fir the specimen collection or is he/she doing he entire annual pap and pelvic exam?

Correct Reporting of HCPCS Code Q0091 for Pap Smear Collection

This came from a BC/BS policy...
Correct Reporting of HCPCS Code Q0091 for Pap Smear Collection

We would like to take this opportunity to remind providers that obtaining a Pap smear is integral to the office visit, including both preventive and routine office visits. Separate reimbursem*nt is not allowed for HCPCS code Q0091.

According to the American Congress of Obstetricians and Gynecologists, code Q0091 should not be reported to non-Medicare payers for Pap smear collection, as the collection of a Pap smear is included in the E&M or preventive service.

The Q0091 code was developed by Medicare for the exclusive purpose of reporting services provided to Medicare patients. Providers should report this code to Medicare only for the collection of screening Pap smears for Medicare patients.

jouanlychen said:

Does anyone know what code to use if only breast exam is perform? and not the pelvic exam?

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I have this same question but it is a Medicare patient so an S code can't be used. I know I can bill the Q0091, but I don't believe I can code the G0101 because the pelivc exam wasn't done. Can I use modifier 52 for reduced service?

Gyn examination

Hi, the way we bill gyn visit to medicare pt is using:
Examplereventive visit with screnning pelvic exam and pap smear ;

99397(GY) with V72.31+ G0101(GA)or (GZ) with V72.31 or V15.89 +Q0091(GA)or (gz), and

if pt has problem diag with bill it as :

99213(25)+G0101(GA) with V76.2-V76.47-V76.49 or V15.89 + Q0091(GA)

I HOPE IT HELP YOU

Medicare Annual with Pap & BE under Anesthia

Can someone help me out with this one, Dr. had a Patient who is disabled and could only handle AE under anesthia which had to be performed at the Hospital for OP? Can anybody help with the cpt codes or Modifiers for this?
Thank you in advance

Primary care & Pap smear

This is the first time I have come across this. I code for a family practice nurse practitioner and primary care physician and today our NP provided a well woman exam and pap smear for a Medicare patient. Please correct me if i am wrong but from my understanding i should bill 99387 (physical age over 65) along with G0101 (pelvic/breast exam) and Q0091 (Pap smear collection)?

Medicare Patient - IPPE/AWV done with PCP - G0101 & Q0091 w/GYN

I have two situations that I need help/clarification on:

1. Medicare Patient has PCP do IPPE/AWV but requests GYN Provider to complete G0101 & Q0091 -
we cannot bill the preventive care diagnosis code again, but if we only use an EM code of 99213 with the G0101 & Q0091 we are not getting any payment. We try to find a problem the patient is experiencing that is documented sufficiently enough to include that as the primary dx - but what can we do if there is no such problem? how can we get paid???

2. Other situation is similar -
Patient comes in for Z01.419 with Z12.4 but has menses at time of appt. Provider reschedules patient for return encounter to complete Pap but then needs to be billed with 99213 since cannot bill Z01.419 again. If no problem to include - how to get paid on this is our other dilemma. \

Tyna Pepe, CPC-A