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Screening Pelvic Examinations
Medicare Claims Processing Manual Chapter 18 §40 (Rev. 1, 10-01-03) B3-4603.2, A3-3, 3628.1B
§4102 of the Balanced Budget Act of 1997 provides for coverage of screening pelvic examinations
(including a clinical breast examination) for all female beneficiaries, subject to certain frequency and
other limitations.
A screening pelvic examination (including a clinical breast examination) should include at least seven (7)
of the following eleven (11) elements:
• 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 (for example, general appearance, hair distribution, or lesions)
• Urethral meatus (for example, size, location, lesions, or prolapse)
• Urethra (for example, masses, tenderness, or scarring)
• Bladder (for example, fullness, masses, or tenderness)
• Vagina (for example, general appearance, estrogen effect, discharge lesions, pelvic support,
cystocele, or rectocele)
• Cervix (for example, general appearance, lesions, or discharge)
• Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or
support)
• Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity)
• Anus and perineum
Coding for Screening Pelvic Examinations
Medicare Claims Processing Manual Chapter 18 §40.2 (Rev. 1, 10-01-03) B3-4603.2.B and C, A3-
3628.1.B.1
A HCPCS code has been established for the pelvic and clinical breast examinations. Use code G0101
(cervical or vaginal cancer screening, pelvic and clinical breast examination).
Coding for Obtaining the Pap smear
Medicare Claims Processing Manual Chapter 18 §30.5.D (Rev. 795, Issued: 12-30-05; Effective: 10-01-
04; Implementation: 04-03-06)
Use HCPCS code Q0091 to report the obtaining a screening pap smear during an encounter. This code is
subject to the same frequencies and diagnoses as pelvic and clinical breast exam.
Payment for Q0091 is paid under the Medicare physician fee schedule. Deductible is not applicable,
however the coinsurance applies.
Effective for services on and after July 1, 2005, on those occasions when physicians must perform a
screening Pap smear (Q0091) that they know will not be covered by Medicare because the low risk
patient has already received a covered Pap smear (Q0091) in the past 2 years, the physician can bill
Q0091 and the claim will be denied appropriately.
The physician shall obtain an advance beneficiary notice (ABN) in these situations as the denial will be
considered a not reasonable and necessary denial. The physician indicates on the claim that an ABN has
been obtained by using the GA modifier.
Effective for services on or after April 1, 1999, a covered evaluation and management (E/M) visit and
code Q0091 may be reported by the same physician for the same date of service if the E/M visit is for a
separately identifiable service. In this case, the modifier “-25” must be reported with the E/M service and
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*All CPT Codes, Descriptions, and Two-Digit Modifiers
Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01
Copyright 2007 Newby Consulting, Inc.