QUEST Integration - Gynecological Examination

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

HMSA’s Plan for QUEST Integration Members covers a gynecological examination, which includes a pelvic examination, Pap smear, clinical breast examination, and mammogram every calendar year. A thin layer preparation screening Pap smear will be covered when it is ordered by a physician in place of a standard Pap smear. Medicare guidelines are followed regarding physician interpretation of a diagnostic or screening Pap smear. The physician interpretation is included in the clinical laboratory fee schedule payment. Therefore, no separate payment is made for the physician interpretation unless the physician is a hospital pathologist interpreting an abnormal smear for a hospital inpatient.

A well-women exam should be billed when the patient sees the physician specifically for a routine gynecological examination. If the patient has gynecological symptoms (e.g., dysmenorrhea) that the physician must evaluate and manage, an E/M visit may be billed.

Referral Requirement

PCP referral is not needed for an well-woman gynecological exam performed each calendar year; however, the claim must clearly indicate through the use of the appropriate ICD10-CM diagnosis code that the visit was for a well-woman annual gynecological exam. When a medical diagnosis code is used, the claim will be denied if there is no evidence of PCP referral.

Note: Specimen collection is considered to be an integral part of the examination and should not be billed separately.

Revision History