If the reported service(s) do not meet the component requirements of the codes billed the services should not be billed. The appropriate medical E/M office visit code (99202-99215) may be reported with modifier 25 in addition to the gynecological examination (G0101). When a physician performs a systemic physical examination as part of an annual gynecological examination and provides an unrelated, separately identifiable E/M on the same day both services may be billed. The below billing guidelines are provided to educate providers on correct billing. The claims reviewed include additional service which are inherent components of the codes such as pap smear collection or digital rectal examinations. Coding & Billing Guidelinesīlue Cross Blue Shield of North Dakota (BCBSND) has identified an increase in providers unbundling Preventive Evaluation and Management (E/M) and/or Gynecological Screening services. This document provides coding and billing guidelines for Gynecological & Rectal Exams.
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