G0101 & Q0091 - What constitutes "high risk"

This week I had the opportunity to utilize CMS's educational resources in regard to all the preventive and/or screening services that Medicare pays for.  This web site is a searchable PDF file.  It has ALL the info you'll need to know.  

I  needed to find out the criteria for "high risk" in regard to the guideline for Medicare's Pap/Pelvic screening code for G0101 and the Q0091.  Medicare will normally only pay for the G0101 screening code once every two years, unless the patient is in a 'high risk" category.  The screening Pap test benefit is covered by Medicare as a stand-alone billable service separate from the IPPE screening benenfit and does not have to be obtained within a certain time frame following a eneficiary's Medicare part "B" enrollment.  Medicare has disclosed the criteria of what 'high risk"  for cervical and vaginal cancer includes.  I've outlined below in the bulleted list

• Early onset of sexual activity (aged 16 and younger)
• Multiple sexual partner (5 or more in a lifetime)
• History of sexually transmitted disease (including human papilliomavirus (HPV) and/or Human Immunodeficiency Virus (HIV) infection
• Fewer than three negative Pap tests or no Pap test within the previous seven year 
• DES (Diethylstilbestrol) exposed daughters of women who took DES during pregnancy 

Additional high risk factors for cervical and vaginal cancer include:

• smoking 
• Using birth control pills for an extended period of time (five or more years) 

If the patient does qualify as a "high risk" patient, the above information needs to be clearly documented within the patient's chart.  In addition to the G0101 and Q0091 code, the diagnosis of V15.89

For women that are not "high risk" - there are a number of diagnoses that are payable once every 2 years.  Those diagnoses are 

V72.31 Routine Gynecological Examination ( NOTE: This diagnosis should only be used when the provider performs a full gynecological examination.)
V76.2 Special screening for malignant neoplasms, cervix
V76.47 Special screening for malignant neoplasms, vagina
V76.49 Special screening for malignant neoplasms, other sites (NOTE: Providers use this diagnosis for women without a cervix.)

The big take-away from this all, is that the physician MUST DOCUMENT if the patient is considered high-risk,  If the patient does not have any of the high risk-factors for cervical or vaginal cancer, yet the patient or physician determines that the patient needs a Pap test yearly, be sure to get an ABN signed, and inform the patient they may be responsible for the cost of the test..    Here's the link for the full PDF document for Medicare preventive services....  http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/mps_guide_web-061305.pdf