GYN Codes,
If we are doing a CPE on the same day we are billing an appropriate 99395, 6, or 7 or what have you. Then we 25 modifier it for separate and distinct as AETNA wants you to as laid out in their settlement, because they will pay for G0101 the actual breast and pelvic exam! Yes many a medical society fought in court for a number of codes and that is one of them. But they will bundle out, Q0091 for the collection of the pap, but we do bill it anyway for all to see their dirty ways.
We are getting resigned to the fact of two separate visits, which is really sexism against the hard working moms or employeed women and their docs who care for them. My female doc gets a lot more of these to do than a similar male doc, right? he gets time to do another quick sick visit while my wife has to wait for the patient to get into a robe, do all of the two exams, collect the darn sample, and then wait for the patient to get dressed again, this is discrimination. I wonder what policy would be if it were an annual penis exam, no chitt.
And as we understand it, Medicare doesn't pay for physicals, but they don't care if you code and bill for all these services on the same day. No coding conflicts. It's balance bill the patient for the CPE that they don't cover. Isn't that great? All these elderly and disabled patients on Medicare and they won't cover an annual well exam. Tell me this country isn't upside down and in a toilet.
Now this little solo office and it's big mouth PM (me!) got one of the larger SCHIPS carriers here in NYS to cover and pay for all of these on the same day! I just won millions of dollars of unpaided claims for thousands of PCP's, GYN's and their paients in the state of NY by myself last year. Even after the lawyers at MSSNY told me to shove off and didn't want to hear about it. Don't you think MSSNY owes my wife an free lifetime membeship seeing what we by ourselves have done???
My arguement was sound and logical. First off here in NYS we have the "women's health and wellness act" because for years these SOB's wouldn't cover such things. So I told them it is our position that they are in violation of the act. You can't go from not covering and not paying to supposedly now covering but still not paying for them (G&Q). Also I used the sexism line.
Plus I used the Mr. Spock like logic of this. Three patients. One goes to their PCP and has all her care done on the same day, CPE with G & Q. They'll only pay for the CPE even though we have done more. Second patient comes in on two days a day apart at the same doctor's office and then they will pay for all 3 codes. Third patient has the CPE in the morning at her PCP's office and then, taking the entire day off from work, she goes to her GYN and has him/her perform G & Q and again the carrier will pay for all codes. So they are penalizing the PCP who takes good care of her patients, is considerate of their time and performs all needed services on the same day. And now Fidelis Care had a number of meetings and now they will pay for all of these performed on the same day. Now obviously we actually have to come thru and deserve such and every now and again for various reasons, such is not appropriate, and so we properly don't submit all codes, which again was another part of my arguement. For example if the patient does have G & Q performed elsewhere or on a different day (she doesn't feel good, wrong part of her cycle) then obviously it is wrong to submit them. And so we don't. I mean doesn't this seem like better and more accurate coding??? Isn't that what they all want out of you folks?
BTW, CCI Edits who is supposed to be a fairly accurate and neutral third party in coding and billing has "no billing and coding conflicts for all of these being performed and submitted for the same day on the same bill. So how come such inappropriate bundling is never prossecuted as a form of insurance fraud, just as our submitting inappropriate unbundling would be in the reverse. Why does my gov't not spend it money and resources agressively protecting patients and providers from such obvious fraud???
Lastly, we should never forget what these exams really are. They are a real form of screening for certain forms of cancer! I'm old enough to remember the messed up false negative paps that lead to the CLIA. The monster of breast cancer has haunted my family since I can remember as a young child. I remember watching my paternal grandmother suffer as she wasted away from late treated breast cancer. It is very personal to me. These fights can not be won on their ballfield of codes and insurance. They must be fought to be won on the our field on right and wrong and they are almost always wrong.
Every time a doc performs a breast and pelvic and collects a PAP, they are screening for potential cancer and they are collecting real cytology, which also requires a chain of custody. Also such docs are exposing themselves to the ever slight but real risk of legal issues. Some of these patients will develop cancer or other changes while under your care, the numbers can't be denyed. Some patients will, whether appropriate or not (yeah, you helped find the darn thing so they could attend to it) will lash out at their provider in such a situation. For all this extra care and risk, don't you guys at least deserve to be paid a bit extra for the services? And yes, the fees the majors pay are not in keeping with their usual percentages of Medicare Fee Schedule. But PCP' are treated on an equal footing to their others in the field, right?
And those W/A speculums cost a few bucks a piece my friends and now they cost even more with the down sizing of the box. And don't forget the paper robe or laundry service too. You probably drop $3-$5 bucks on each one of these when you add it all up. But you're not entitled to some extra compensation. Oh yeah, and you've got to properly disposed of that speculum too don't forget.
Yeah, yeah, I'm a PM, but someone's got to watch the store around here, while the gov't ties you docs up in knots.
