Screening Pelvic Examinations (includes a clinical breast examination)
G0101 – Cervical or vaginal cancer screening; pelvic and clinical breast examination
High risk – Z77.22, Z77.9, Z91.89, Z72.89, Z72.51, Z72.52, and Z72.53
Low risk – Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.89
Who Is Covered
All female Medicare beneficiaries Frequency
* Annually if at high risk for developing cervical or vaginal cancer or childbearing age with abnormal Pap test within past 3 years
* Every 2 years for women at normal risk
Medicare Beneficiary Pays
* Copayment/coinsurance waived
* Deductible waived
SCREENING PELVIC EXAM
Medicare reimburses for a screening pelvic examination every two years in most cases. This service is reported using HCPCS code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). If the patient meets Medicare’s criteria for high risk, the examination is reimbursed every year. These criteria are the same as the ones listed above for the collection of screening Pap smear specimen. The diagnosis codes for pap smear collection and screening pelvic exam are listed below.
Effective September 23, 2008, Medicare clarified that the clinical breast check is no longer considered a mandatory element of the screening pelvic exam. It is now one of the eleven elements that may be performed as part of the exam.
A screening pelvic examination (HCPCS code G0101) should include documentation of at least seven of the following eleven elements:
• Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge;
• Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses;
• External genitalia (for example, general appearance, hair distribution, or lesions);
• Urethral meatus (for example, size, location, lesions, or prolapse);
• Urethra (for example, masses, tenderness, or scarring);
• Bladder (for example, fullness, masses, or tenderness);
• Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);
• Cervix (for example, general appearance, lesions or discharge)
• Uterus (for example, size, contour, position, mobility, tenderness, consistency,
descent, or support);
• Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity);and
• Anus and perineum.
HCPCS code G0101 includes only the above examination elements. It does not include many other services normally included in a comprehensive preventive visit.
Q0091 Cervical or vaginal cancer screening; pelvic and clinical breast examination
A Screening Pap Smear (HCPCS code Q0091) and/or the Cervical or Vaginal Cancer Screening (G0101) is considered part of a preventive or problem based office visit and is not separately reimbursable. As of February 21, 2011, the screening services of Q0091 and/or G0101 are considered for separate reimbursement when reported in addition to a significant and separately identifiable E/M service. Modifier 25 must be appended to the E/M service for the screening services to be separately reimbursed. Documentation supporting the unrelated E/M service meeting the Modifier 25 requirements must be maintained and made available to us upon request.
Exception: Q0091 and G0101 will remain a component of a Preventive Medicine E/M Service and will not be separately reimbursed. Modifier 25 appended to the Preventive Medicine E/M CPT Codes will not override the edit (Preventive Medicine E/M CPT codes 99381- 99397).