Forum - Questions & Answers

Jan 27th, 2010 - slefevre 5 

G0101

Please tell me where the guideline that a breast exam is mandatory to report G0101 is. I do not see that in the Medicare guidelines, only that screening pelvic exams also have included the breast as an exam element, not that a breast exam is mandatory. I read the guidelines as there needs to be documentation of 7 of 11 exam elements of which the breasts could be one.

Please clarify your guidance that a breast exam is mandatory to report G0101.

Thanks,

Susan

Jan 27th, 2010 -

You are correct

that breast exam is part of the list and it says at least 7 of the elements but it also says "Medicare’s covered pelvic examination includes a complete physical examination of a woman’s external and internal reproductive organs by a physician or qualified non-physician practitioner. In addition, the pelvic examination includes a clinical breast examination, which aids in helping to detect and find breast cancer or other abnormalities."

I do it- the 10 seconds it takes is worth it to guarantee I pass an audit.

I should add that there is no data that clinical breast examination actually finds cancer and is worthless.

Jan 28th, 2010 - Codapedia Editor 1,399 

G0101 does require a breast exam

CMS clarified this in a transmittal not long ago. THey said it wasn't a change in policy. Ch 18 of the Claims processing manual says this, and I interpret this to mean that the breast exam must be included.

40 - Screening Pelvic Examinations
(Rev. 1541, Issued: 06-20-08, Effective: 09-23-08, Implementation: 09-23-08)
Section 4102 of the BBA of 1997 (P.L. 105-33) amended §1861(nn) of the Act (42 USC
1395X(nn)) to include Medicare Part B coverage of screening pelvic examinations
(including a clinical breast examination) for all female beneficiaries for services provided
January 1, 1998 and later. Effective July 1, 2001, the Consolidated Appropriations Act of
2001 (P.L. 106-554) modifies §1861(nn) to provide Medicare Part B coverage for
biennial screening pelvic examinations. A screening pelvic examination with or without
specimen collection for smears and cultures, should include at least seven of the
following eleven elements:

Jan 28th, 2010 - slefevre 5 

G0101 the clarified transmittal regarding the breast exam.

The last transmittal that I found was #1541. To me, it does not state that a breast exam MUST be done. To me, the guidance is simply indicating that the breast exam would be considered a part of G0101, IF done. It seems (including a breast examination) is part of the guidance because we all know that the breasts are not a part of the pelvic area. It clarifies that the breasts are considered to be part of the eleven exam elements of a pelvic exam.

If the breast exam was a requirement, wouldn't the listing of exam elements be as:

-inspection and palpation of breasts for masses or lumps, tenderness,symmetry, or nipple discharge

AND

6 of the following 10 elements:?

What if the patient didn't want her breasts examined and only wanted a pelvic exam? Does that mean the provider can't report G0101 if seven other exam elements were done but not the breast exam? Does that mean tough for the patient, she has to have a breast exam? I don't think either situation is correct.

Is there another transmittal available?

Thanks,

Susan

Jan 28th, 2010 - nmaguire   2,606 

breast exam

http://www.cms.hhs.gov/transmittals/downloads/r1541cp.pdf
I believe that this transmittal clarified that 7 of the 11 must be documented, that speaks for itself. A breast exam could be one of the 11, but not required.

Jan 28th, 2010 - slefevre 5 

G0101

I agree, but that is not what the Codapedia editor has stated. I have seen no later transmittal than the 6/20/2008 transmittal #1541. I am hoping that the Codapedia editor will respond to my posting again.

Thanks

Jan 28th, 2010 - nmaguire   2,606 

Breast exam

I taught for many years and the code descriptor itself separates these elements. CMS is not known for clear instructions. That is why the Transmittal was issued. It can be a confusing and frustrating profession, that is why this sharing of experiences and ideas on Codapedia is so valuable. I sometimes have to rethink policies because what is good today, may be obsolete tomorrow!

Jan 28th, 2010 - slefevre 5 

breast exam

Do you agree that if the guidance meant that a breast exam had to be done in order to bill G0101, that the exam elements would be listed with the breast exam and 6 of the other 10 exam elements as I wrote in an earlier e-mail? I cannot imagine that our government would say that a patient HAS to have a breast exam and that would be what they would be saying if they didn't pay G0101 without one.

Jan 28th, 2010 -

Oh really?

[ we all know that the breasts are not a part of the pelvic area. ]


You haven't seen the women on the website peopleofwalmart.com - there are some breasts that get awfully close to the pelvic area!



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