How is a breast and pelvic exam coded for a Medicare patient?

Medicare Coding for Breast and Pelvic Examinations

For Medicare patients, a breast and pelvic exam should be coded using G0101, not the preventive medicine codes (99387/99397) used for non-Medicare patients.

Medicare-Specific Coding Requirements

Medicare has established specific HCPCS codes for preventive services that differ from the standard CPT codes used for non-Medicare patients. This distinction is critical for proper reimbursement.

Medicare vs. Non-Medicare Coding:

• Non-Medicare patients: Age-appropriate preventive medicine codes (99381-99397) are used for comprehensive preventive visits including breast and pelvic exams
• Medicare patients: Specific HCPCS codes are required for preventive services

Proper Medicare Coding for Breast and Pelvic Exams:

• G0101: Code for "Cervical or vaginal cancer screening; pelvic and clinical breast examination" 1
• Medicare covers pelvic examination and clinical breast examination for female beneficiaries

Medicare Coverage Guidelines

Medicare provides specific coverage for breast and pelvic examinations as preventive services:

• Pap testing and pelvic examination covered at three-year intervals for average-risk women 1
• Annual screening is allowed for women at high risk of cervical or vaginal cancer or who have had an abnormal Pap smear in the preceding three years 1

Clinical Components Required for G0101

To properly bill G0101, the examination must include at least 7 of the following 11 elements:

1. Inspection and palpation of breasts for masses or lumps
2. Examination of axillae for adenopathy
3. Inspection of external genitalia
4. Examination of urethra and urethral meatus
5. Inspection of vagina
6. Palpation of adnexa/parametria
7. Inspection of cervix
8. Obtaining specimens for cervical cytology (if indicated)
9. Palpation of uterus
10. Palpation of ovaries
11. Obtaining specimens for STI screening (if indicated)

Documentation Requirements

Proper documentation is essential for Medicare reimbursement:

• Document all elements performed during the examination
• Clearly indicate medical necessity when performing more frequent examinations than the standard coverage allows
• Include appropriate risk factors when billing for annual rather than triennial examinations

Common Pitfalls to Avoid

• Using preventive medicine CPT codes (99387/99397) for Medicare patients instead of G0101
• Failing to document the required number of examination elements
• Not indicating high-risk status when billing for annual examinations
• Overlooking the need for separate coding of the Pap smear specimen collection (Q0091) if performed

By using the G0101 code for Medicare patients requiring breast and pelvic examinations, providers ensure proper reimbursement while complying with Medicare's specific coding requirements.