Seven: Magic number for pelvic exam reimbursement
Seven: Magic number for pelvic exam reimbursement
Coverage frequency varies by patient risk
"The only constant is change," the old saying goes. Last summer’s Balanced Budget Act proved the saying true by adding some new requirements for physician practices with Medicare patients.
One area you’ll need to take particular note of: new requirements for coverage of pelvic exams performed on female patients. Health Care Financing Administration (HCFA) now requires that an examination include at least seven of the standard 11 screening elements that are included in the Medicare manual.
Screening pelvic examinations are also covered for every female Medicare beneficiary every three years. A screening pelvic examination is covered annually for certain women of child-bearing age, and for those at "high risk" for cervical or vaginal cancer.
HCFA defines high risk for cervical cancer based on the onset of sexual activity, whether the woman has had multiple sexual partners or a history of sexually transmitted diseases, the absence of three negative Pap smear results in the last seven years, or the failure to have a Pap smear performed in the last seven years.
In the case of vaginal cancer, the term high risk is defined to mean prenatal exposure to diethylstilbestrol.
Pelvic screenings may be billed under code G0101 and will be paid at the rate of a Level 2 evaluation and management new patient office visit.
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