CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Annual gynecological exam billing (S0610, S0612)

Defines coding, documentation and reimbursement guidance for billing annual gynecological exam HCPCS codes S0610 (new patient) and S0612 (established patient) for Neighborhood Health Plan of Rhode Island's network of Community Health Centers and professional services billed on a CMS-1500 form.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnnual gynecological exam billing (S0610, S0612)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2013

Next Review DateN/A

Key ActionFee-for-service payment is allowed for 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, S0612Applicable HCPCS codes covered

Fee-for-servicePayment type

99383-99387; 99393-99397Mutually exclusive with

CHC / CMS-1500Applies to

Coverage and Billing Rules

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnnual gynecological exam billing (S0610, S0612)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2013

Next Review DateN/A

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

SourceLink

On This Page

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ALL of the following

Fee-for-service payment will be allowed when annual gynecological services are billed with codes S0610 and S0612.
Do not bill S0610 or S0612 in conjunction with capitated preventive care service codes 99383-99387 or 99393-99397; billing both may result in claim denials for exceeding benefits limits.
Policy applies to Neighborhood's network of Community Health Centers (CHC) and to professional services billed on a CMS-1500 form.
This guideline is not a guarantee of reimbursement; Plan coverage, eligibility and claim payment edit rules may apply.
Operational note: Providers should verify member eligibility and benefit coverage prior to billing.

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Relevant HCPCS Codes and Billing Restrictions

Annual gynecological exam HCPCS codesHCPCSCovered

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

Mutually exclusive billing

Mutually exclusive billingS0610 and S0612 should not be billed in conjunction with capitated preventive care service codes 99383-99387 or 99393-99397 (may result in claim denials).

Applicable settingApplies to Neighborhood's network of Community Health Centers (CHC).

Claim formPolicy applies to professional services billed on a CMS-1500 form.

Billing Guidance and Action Items for Providers

Billing Rule

Billing and prior authorization notes for S0610/S0612

Fee-for-service payment is allowed when annual gynecological services are billed with HCPCS 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; billing both may result in claim denials for exceeding benefits limits. This policy applies to the Plan's network of Community Health Centers (CHC) and to professional services billed on a CMS-1500 form. The guideline is not a guarantee of reimbursement — plan coverage, eligibility and claim payment edit rules may still apply.

Fee-for-service payment permitted for S0610 and S0612.
Do not bill S0610 or S0612 with 99383-99387 or 99393-99397 (may result in denials).
Applies to Neighborhood's network of Community Health Centers (CHC) and to professional services billed on a CMS-1500 form.
Guideline is not a guarantee of reimbursement; coverage and claim edit rules may apply.

Code Definitions

Annual gynecological exam — new patient

HCPCS codeS0610

DescriptionAnnual gynecological exam, new patient.

PaymentFee-for-service payment will be allowed when billed for annual gynecological services.

Billing noteDo not bill S0610 in conjunction with capitated preventive care service codes 99383-99387 or 99393-99397 (may result in claim denials).

Annual gynecological exam — established patient

HCPCS codeS0612

DescriptionAnnual gynecological exam, established patient.

PaymentFee-for-service payment will be allowed when billed for annual gynecological services.

Billing noteDo not bill S0612 in conjunction with capitated preventive care service codes 99383-99387 or 99393-99397 (may result in claim denials).