The Well Woman Exam
Crystal Tompkins CDEO, CPMA, CPC, CRC, COBGC, and Educator and Auditor
September 13, 2024
I will never forget the wonder of being asked to write an article for NAMAS. The nerd in me was ecstatic, and the auditor/coder in me was completely in shock. After that feeling subsided, reality quickly set in, and I began to research for all I was worth. I know this subject, I educated myself on this subject, and still, I went right back to the basics.
Why is the Well Woman visit so important? In football, we learn that the best defense is a good offense. In other words, the best way to give yourself the opportunity to succeed is to secure yourself against risk or danger. This is the same with the Well Woman visits, as they allow us to reduce risk and prevent problems before they become, well, problems.
Commercial and Medicaid:
The American College of Obstetricians and Gynecologists, ACOG, and the Women’s Preventive Services Initiative, WPSI, tell us that the well woman should include the following:
- Comprehensive history and exam
- Reproductive life plan, which includes pregnancy counseling, infertility assessment, and contraception options
- Counseling on a healthy lifestyle and minimizing health risks
- Counseling and immunizations based on age and risk factors
- Screening certain cancers (breast, cervical, and colorectal)
Both ACOG and WPSI believe that the Well Woman Exam should be done annually for all females who are sexually active or over the age of eighteen. Commercial Insurance and Medicaid typically follow the above guidelines and frequency. The following codes are used for billing the Well Woman Exams:
New Patients: 99381-99387
Established Patients: 99391-99397
CMS/ Medicare further breaks the Well Woman visit by dividing it into two parts. Those two parts are the pap test and the breast/ pelvic exam. CMS guidance does state that the breast/ pelvic exam and pap test should be done at a two-year frequency unless the participant is considered high-risk. Factors that are considered high risk are early onset of sexual behavior (before the age of 16), five or more sexual partners in a lifetime, history of a sexually transmitted infection, fewer than 3 negative pap tests, no pap tests within the previous seven years, and exposed daughters of women who took Diethylstilbestrol (DES) during pregnancy.
The breast and pelvic exam would be billed using code G0101. The exam includes eleven elements. Seven of those elements must be met, one of which is the breast exam, to meet the guideline requirements.
Exam elements include:
- Inspection and palpation of the breasts for lumps, tenderness, symmetry, or nipple discharge*this is a required element
- Digital rectal exam
- Pelvic exam
- External genitalia
- Urethral meatus
- Bladder
- Urethra
- Vagina
- Cervix
- Uterus
- Adnexa/ parametria
- Anus and perineum
Per CMS, if the pelvic exam is done at a problem visit, the pelvic exam is not separately reportable. The exam would be considered part of the EM service.
The collection of the pap test is a separately reportable service and can be billed with code Q0091.
In conclusion, the Well Woman Exam is a preventive measure that focuses on sexual and reproductive health and allows the early detection of problems that could potentially pose a threat to women.
Sources Cited:
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Screening-PapPelvic-Examinations.pdf
- https://www.womenspreventivehealth.org/
- https://www.acog.org/topics/well-woman-health-care#:~:text=Women%27s%20Preventive%20Services%20Initiative,-The%20goal%20of%20WPSI%20isCMS:
About Ms.Tompkins:
Crystal Tompkins is an auditor and coding educator who found her passion in researching coding guidelines and education. I am a current local chapter president and find joy in presenting coding education to chapters all over the United States and the Bahamas. Ms. Tompkins’s current employment is with NGPG and GHI.
