We have received reports that there are many OBGYN physicians experiencing take-backs by Anthem (Wellpoint) and Medical Mutual of Ohio. These payers were in the practice of paying for Q0091 pap-obtaining when a woman had a pap smear along with an annual exam. ACOG had previously pointed out that some carriers would pay the code. The carriers are pointing to ACOG guidance that the
One coder when contacted gave the following justification for including the code. “When a patient goes to an internal medicine physician and that physician performs a preventive exam, and does not collect a pap smear but allows the patient to return to a family physician or a Gynecologist for the service, the insurance carrier would be paying for the preventive service and for the pap obtaining separately. So, why shouldn’t the physician get the payment for the service?” Additionally, if the patient were to come back on a separate day for just a pap smear, the insurance company would pay for it, so why do we make the providers play games just to get the reimbursement?”
Another coder posts “I would like to fight this with MMO because they clearly did not have a policy in place to prevent them from paying a pap with a preventative and if they have just now discovered the ACOG statement stating they should not pay it then they should correct their system going forward and leave what has already been paid as is.” When we contacted the carrier, “we were told we should be happy because there were others who had a lot more than us that was taken back”
We tend to agree with the coders using the logic that in that an annual exam for a woman in her 50s or 60s where no pap is indicated is not paid any less than those where the handling of a specimen is required. We would be curious on your feedback on this question.