G0101 Pelvic and breast exam
July 6th, 2009 - Codapedia Editor
Medicare does not pay for routine physical exams annually for patients--a sore spot for Primary Care Providers and Medicare beneficiaries alike. They do pay for an initial Welcome to Medicare visit. (See the Codapedia article about that topic.)
Medicare does pay for a screening pelvic and breast exam, yearly for high risk patients and every two years for low risk patients. Bill for this service with code G0101. Medicare also pays for obtaining a screening pap smear, using code Q0091.
G0101 is defined as: Cervical or vaginal cancer screening; pelvic and clinical breast examination
Q0091 is defined as: Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
There is a CMS reference guide in the resource section of this article that lists all Medicare covered preventive services, with the frequency and diagnosis codes.
Use covered diagnosis codes (V76.2, V76.47, V76.49, V15.89, V72.31)
Pelvic/breast exam G0101
Requires 7 of 11 exam elements
Examination of the breast is mandatory to bill G0101
• Inspection and palpation of the breasts for lumps, tenderness, symmetry or nipple discharge
• Digital rectal exam
Pelvic exam including:
• External genitalia
• Urethral meatus
• Bladder
• Urethra
• Vagina
• Cervix
• Uterus
• Adnexa/parametria
• Anus and perineum
This service may be billed on the same date as an Evaluation and Management service (office visit, for example) but in that case, use modifier 25 on the office visit. Link the diagnosis codes appropriately: screening for the G0101 and the medical condition for the office visit.
Q0091 is for obtaining a screening not a diagnostic pap smear. There is no separate code for obtaining a diagnostic pap smear. 99000, obtaining a lab specimen, is bundled by Medicare and rarely paid by other payers.
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)
Artificial Intelligence in Healthcare - A Medical Coder's PerspectiveDecember 26th, 2023 - Aimee WilcoxWe constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities?
Specialization: Your Advantage as a Medical Coding ContractorDecember 22nd, 2023 - Find-A-CodeMedical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)December 19th, 2023 - Aimee WilcoxChronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike AgainDecember 12th, 2023 - Aimee WilcoxAccording to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for AppendicitisNovember 14th, 2023 - Aimee WilcoxWith approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023October 26th, 2023 - Wyn StaheliCOVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M ServicesOctober 11th, 2023 - Wyn Staheli2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
