COBGC Payer-Specific Guidelines 2 — Questions and Answers
Question 1: Under Medicare, which obstetric service is typically covered as a preventive benefit with no cost-sharing when billed with the appropriate preventive modifier?
- Annual well-woman exam (G0101/Q0091) (Correct answer)
- Global obstetric package
- Elective cesarean delivery
- Amniocentesis for genetic testing
Correct answer: Annual well-woman exam (G0101/Q0091)
Medicare covers the annual pelvic exam and Pap smear screening (G0101 and Q0091) as a preventive benefit, subject to frequency limits and with no beneficiary cost-sharing when billed with modifier -33.
Question 2: Medicaid programs in most states require prior authorization for which of the following gynecologic procedures?
- Colposcopy following an abnormal Pap smear
- Hysterectomy for non-emergent indications (Correct answer)
- Routine prenatal office visit
- IUD insertion for contraception
Correct answer: Hysterectomy for non-emergent indications
Hysterectomy is a high-cost, major surgical procedure that most state Medicaid programs require prior authorization for when performed for non-emergent indications.
Question 3: When a Medicare beneficiary is also covered by an employer group health plan (EGHP) through a spouse's employer, which payer is primary for an OB/GYN procedure?
- Medicare is always primary for beneficiaries over 65
- The EGHP is primary; Medicare is secondary (Correct answer)
- The payer with the higher allowed amount is primary
- Medicaid coordination rules apply instead
Correct answer: The EGHP is primary; Medicare is secondary
Under Medicare Secondary Payer (MSP) rules, an active employer group health plan is primary over Medicare when the group has 20 or more employees.
Question 4: NCCI (National Correct Coding Initiative) edits apply primarily to claims submitted to which payer?
- Commercial insurers only
- Medicare and Medicaid (CMS programs) (Correct answer)
- TRICARE exclusively
- All payers equally by federal law
Correct answer: Medicare and Medicaid (CMS programs)
NCCI edits were developed by CMS and apply to Medicare and Medicaid claims, though many commercial payers have adopted similar bundling logic.
Question 5: Medicare does NOT cover which of the following fertility-related services?
- Diagnostic laparoscopy to evaluate pelvic pain
- In vitro fertilization (IVF) (Correct answer)
- Hysteroscopy to remove a uterine polyp
- Ultrasound for abnormal uterine bleeding
Correct answer: In vitro fertilization (IVF)
Medicare explicitly excludes coverage of infertility treatments including IVF; diagnostic procedures for other conditions that may incidentally affect fertility can still be covered.
Question 6: Which modifier is required when billing Medicare for a surgical procedure performed during the global period of a previous surgery by the same physician?
- Modifier -24
- Modifier -79 (Correct answer)
- Modifier -57
- Modifier -25
Correct answer: Modifier -79
Modifier -79 indicates an unrelated procedure or service performed by the same physician during the postoperative period of a prior surgery.
Question 7: A patient on Medicaid delivers via cesarean section. The provider wants to bill separately for the post-partum visit at 6 weeks. How do most state Medicaid programs handle this?
- It is always bundled into the global OB package and not separately payable
- It may be billed separately using the appropriate E/M code with modifier -24 (Correct answer)
- Medicaid never covers post-partum visits
- Post-partum visits require a separate prior authorization
Correct answer: It may be billed separately using the appropriate E/M code with modifier -24
Most Medicaid programs follow a global OB package concept but allow the post-partum visit to be billed separately with modifier -24 to indicate it falls within the global period but is a distinct service.
COBGC Payer-Specific Guidelines 2
Under Medicare, which obstetric service is typically covered as a preventive benefit with no cost-sharing when billed with the appropriate preventive modifier?