What is the Medicare Current Procedural Terminology (CPT) code for a women's health exam for a patient 21 years or older?

Medicare CPT Codes for Women's Health Exam (Age 21+)

For a comprehensive women's health exam in Medicare patients aged 21 or older, use CPT code G0101 (cervical/vaginal cancer screening including pelvic and clinical breast examination) when performed as a preventive service, or standard office visit codes (99201-99205 for new patients, 99211-99215 for established patients) when performed as part of an evaluation and management service.

Preventive Service Coding

G0101 - Cervical or Vaginal Cancer Screening

• This Medicare-specific code covers the pelvic examination and clinical breast examination when performed as part of preventive screening 1
• Includes inspection for suspicious lesions or signs of sexually transmitted diseases during the genital examination 1
• Can be billed once every 24 months for average-risk women, or annually for high-risk women 1

Q0091 - Pap Smear Collection

• Use this code separately for obtaining the cervical cytology specimen 1
• For women aged 21-65 years, screening should occur every 3 years with conventional or liquid-based Pap tests 1
• For women aged 30-65 years, screening every 5 years with combined HPV and Pap testing is preferred, or every 3 years with Pap test alone is acceptable 1

Evaluation and Management Coding Alternative

Office Visit Codes (99201-99215)

• When the women's health exam is performed as part of a problem-oriented visit rather than pure preventive care, use standard E/M codes 2
• Code selection requires meeting 2 of 3 medical decision-making (MDM) elements: problems addressed, data reviewed, and risk of complications 2
• Time-based coding is an alternative if counseling dominates more than 50% of the visit 2, 3

Component Services to Document

Clinical Breast Examination

• For women in their 20s and 30s, perform every 3 years as part of periodic health examination 1, 4
• For women aged 40 and older, perform annually, preferably prior to mammography 1, 4
• ACOG recommends annual examination for all women aged >19 years 1

Cervical Cancer Screening

• Begin at age 21 years regardless of sexual activity onset 1
• Never screen women under age 21 years (Grade D recommendation) 1
• Women over age 65 with 3 consecutive normal Pap tests or 2 consecutive negative HPV and Pap tests within the last 10 years may discontinue screening 1, 4
• Women with total hysterectomy for benign conditions should stop screening 1, 4

Genital Examination

• Must accompany cervical cancer screening to inspect for suspicious lesions or signs indicating undiagnosed STDs 1
• Document inspection of external genitalia, vaginal walls, and cervix 1

Common Pitfalls to Avoid

• Do not bill G0101 and a standard office visit code on the same date unless the office visit addresses a separate, significant problem requiring additional evaluation beyond the preventive service 2, 5
• Do not screen annually with any cervical cancer screening method - this is explicitly not recommended and will result in claim denials 1
• Do not perform Pap smears on women under age 21 - this is a Grade D recommendation (harm outweighs benefit) 1
• Do not delay contraceptive initiation for cervical cytology results 1
• Do not use outdated annual screening intervals - cervical cancer screening frequency has changed from annual to every 3-5 years depending on age and test type 1

Additional Screening Considerations

Risk Assessment

• Document family history of breast and ovarian cancers in first-degree and second-degree relatives on both maternal and paternal sides going back 3 generations 1
• Women with identified BRCA mutation risk factors should be referred for genetic counseling 1

Mammography Referral

• Annual mammography should begin at age 40 years per ACS guidelines 1, 4
• USPSTF recommends biennial screening for women aged 50-74 years 1