Pelvic Exam Screenings

by  Find-A-Code™
Jan 1st, 2019 - Reviewed/Updated May 18th

A pelvic exam screening is a preventive exam of the female reproductive organs to detect disease in an asymptomatic patient. Proper reporting of these services depends on the payer since Medicare and commercial payer policies vary.

Commercial payers generally prefer the use of a Preventive E/M code (99381-99397) or a HCPCS code (S0610, S0612, S0613) to report these services. However, for Medicare (and other payers following Medicare guidelines), use code G0101. To ensure proper reporting, check individual payer policies to see their preferred codes.

Alert: Reporting of Preventive Medicine codes is NOT based on the Elements of Medical Decision Making required for other E/M visits (e.g., 99202-99215). Instead, the required elements are: an age and gender appropriate history and examination counseling/anticipatory guidance/risk factor reduction interventions ordering of laboratory/diagnostic procedures

There are some other codes to consider which may be reported, as applicable. They are:

• Collection of screening Pap smear: Q0091, G0101, and/or problem-oriented E/M may all be reported as appropriate. If there is an unsatisfactory smear specimen, it is appropriate to report Q0091 with modifier 76 to bill for this service.
• There are two other codes for reporting screening Pap tests. Code P3001 will require a separate report by a physician with interpretation of the findings of the Pap smear. The codes are:

Note: Human papillomavirus (HPV), testing is covered by Medicare for asymptomatic patients 30-65 years of age. It is covered once every five years when billed in conjunction with a Pap test. (CLICK HERE to read more about cervical cancer screening)

Medicare Coverage of Pelvic Examinations

• At-Risk: According to Medicare,
  • “A woman of childbearing age who has had a Pap test during any of the three (3) preceding years that indicated the presence of cervical or vaginal cancer or other abnormality.”
  • Childbearing age is: “a woman who is premenopausal and determined by physician or qualified practitioner to be of childbearing age based on medical history or other findings.”
• High Risk: high risk factors for cervical and vaginal cancer include:
  • Early onset of sexual activity (under 16 years of age)
  • Multiple sexual partners (five or more in a lifetime)
  • History of STI (including human immunodeficiency virus [HIV] infection)
  • Fewer than three negative Pap tests or no Pap tests within the previous seven (7) years
  • Women exposed to DES* in utero
    • *DES is a synthetic form of estrogen which was given to women between 1940 and 1971 to prevent miscarriage, premature labor, and certain complications of pregnancy. In 1971, researchers linked prenatal exposure to DES to clear cell adenocarcinoma and the FDA notified physicians to discontinue prescribing DES to pregnant women.

Tip: CLICK HERE to review additional information by Medicare on Pap tests and pelvic examinations, including coverage and billing information.

Medicare Documentation Requirements for a Pelvic Exam

CMS requires that the documentation for code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) includes at least seven of the following:

• 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;
• Pelvic examination (with or without specimen collection for smears and cultures) including:
  • External genitalia (e.g., general appearance, hair distribution, or lesions)
  • Urethral meatus (e.g., size, location, lesions, or prolapse) Urethra (e.g., masses, tenderness, or scarring)
  • Bladder (e.g., fullness, masses, or tenderness)
  • Vagina (e.g., general appearance, estrogen effect, discharge lesions, pelvic support, cystocele, or rectocele)
  • Cervix (e.g., general appearance, lesions, or discharge)
  • Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent, or support)
  • Adnexa/parametria (e.g., masses, tenderness, organomegaly, or nodularity)
  • Anus and perineum.

– Source: Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer (NCD 210.2)