COBGC Payer-Specific Guidelines 2

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?

Accepted Answer

Annual well-woman exam (G0101/Q0091)

Answer

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?

Accepted Answer

Hysterectomy for non-emergent indications

Answer

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?

Accepted Answer

The EGHP is primary; Medicare is secondary

Answer

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?

Accepted Answer

Medicare and Medicaid (CMS programs)

Answer

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?

Accepted Answer

In vitro fertilization (IVF)

Answer

Medicare explicitly excludes coverage of infertility treatments including IVF; diagnostic procedures for other conditions that may incidentally affect fertility can still be covered.

(COBGC) Certified Obstetrics Gynecology Coder Practice Test

(COBGC) Certified Obstetrics Gynecology Coder Practice Test

COBGC Payer-Specific Guidelines 2