Medicare does not pay for routine physical exams annually for patients – a sore spot for gynecologists, primary care providers and Medicare beneficiaries alike. They do pay for an initial Welcome to Medicare visit, an initial wellness visit and subsequent wellness visits. The wellness visits are usually done by family physicians, internists and geriatricians, and less frequently by gynecologists.
Medicare does pay for a screening pelvic and breast exam, annually if the patient is at high risk for developing cervical or vaginal cancer, or of childbearing age with an abnormal Pap test within the last 3 years or every two years for women at normal risk. Bill for this service with code G0101.
Medicare also pays for obtaining a screening pap smear, using code Q0091 with the same frequency requirements as above. The copayment/co-insurance and deductible are waived for both services.
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
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
- Anus and perineum
Can I bill these codes in addition to an E/M service or wellness visit?
A pelvic exam done at a problem oriented visit does not have a separate code, and G0101 should not be used for it. That exam is part of the E/M service. There is no code for a breast exam only.
G0101 may be billed on the same date as an Evaluation and Management service (office visit, for example) or wellness visit, but in that case, use modifier 25 on the office visit/wellness visit.
Link the diagnosis codes appropriately: screening for the G0101 and the medical condition for a problem oriented E/M service. Wellness visits are typically billed with code Z00.00 or Z00.01 in the first position. The patient’s chronic conditions may also be added to the claim form, if addressed.
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 many other payers.
According to CMS, the covered diagnoses for reporting G0101 and Q0091 are
- Z72.51 High risk heterosexual behavior
- Z72.52 High risk homosexual behavior
- Z72.53 High risk bisexual behavior
- Z77.29 Contact with and (suspected) exposure to other hazardous substances
- Z77.9 Other contact with and (suspected) exposures hazardous to health
- Z91.89 Other specified personal risk factors, not elsewhere classified
- Z92.89 Personal history of other medical treatment
- Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
- Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
- Z12.4 Encounter for screening for malignant neoplasm of cervix
- Z12.72 Encounter for screening for malignant neoplasm of vagina
- Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
- Z12.89 Encounter for screening for malignant neoplasm of other sites
CMS’s entire document on preventive services can be found on their website, link below.