CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Annual gynecological exam billing (CPT S0610, S0612)

Defines coding, documentation, and reimbursement rules for billing annual gynecological services using CPT codes S0610 and S0612 for Neighborhood Health Plan of Rhode Island's Community Health Centers network; applies to professional services billed on a CMS-1500 form.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnnual gynecological exam billing (CPT S0610, S0612)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2013

Next Review Date

Key ActionFee-for-service payment allowed when billed with codes S0610 and S0612; do not bill these with capitated preventive codes 99383-99387 or 99393-99397.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S0610, S0612Covered annual gynecological exam CPT codes

Community Health CentersProvider network this policy applies to

CMS-1500Form required for professional services billing

99383-99387, 99393-99397Preventive codes that must not be billed with S0610/S0612

Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnnual gynecological exam billing (CPT S0610, S0612)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2013

Next Review Date

Key ActionFee-for-service payment allowed when billed with codes S0610 and S0612; do not bill these with capitated preventive codes 99383-99387 or 99393-99397.

SourceLink

On This Page

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Annual gynecological exam coverage criteria

Covered when ALL of the following are met:

ALL of the following

Fee-for-service payment is allowed when annual gynecological services are billed with CPT codes S0610 (annual gynecological exam, new patient) and S0612 (annual gynecological exam, established patient).
Applies to Neighborhood Health Plan of Rhode Island's network of Community Health Centers (CHC).
Applies to professional services billed on a CMS-1500 form.
S0610 and S0612 must NOT be billed in conjunction with capitated preventive care service codes 99383-99387 or 99393-99397; billing such combinations may result in claim denials for exceeding benefits limits.
Do not combine S0610/S0612 with 99383-99387 or 99393-99397; claims may be denied.

Covered codes

CPT S0610 — Annual gynecological exam, new patient.
CPT S0612 — Annual gynecological exam, established patient.

Coding and Code Restrictions

Annual gynecological exam codesCPTCovered

S0610	Annual gynecological exam, new patient
S0612	Annual gynecological exam, established patient

Preventive care codes not to combineCPTNot Covered

99383-99387	Capitated preventive care service codes (new)
99393-99397	Capitated preventive care service codes (established)

Claims combination limit

Claim combination ruleDo not bill CPT codes S0610 or S0612 in conjunction with capitated preventive care service codes 99383-99387 or 99393-99397; combining these may result in claim denials for exceeding benefits limits.

Affected preventive codes99383-99387 (new) and 99393-99397 (established)

Consequence of combinationMay trigger claim denials due to exceeding benefits limits.

Applicable provider networkNeighborhood Health Plan of Rhode Island Community Health Centers (CHC)

Provider Actions and Billing Rules

Billing Rule

Annual gynecological exam billing rules

Fee-for-service payment is allowed when annual gynecological services are billed with CPT codes S0610 (new patient) and S0612 (established patient). Do not bill S0610 or S0612 in conjunction with capitated preventive care service codes 99383-99387 or 99393-99397; combining these codes may result in claim denials for exceeding benefits limits.

Applies to professional services billed on a CMS-1500 form.
Applies to Neighborhood Health Plan of Rhode Island's Community Health Centers network.

OpenPayer

Annual gynecological exam billing (CPT S0610, S0612)

Coverage Criteria

Coding and Code Restrictions

Provider Actions and Billing Rules

Definitions