Wiki Medicare GYN Exam- G0101

[NicoleSprecher]

Hello,

I was asked by one of our physicians to explain in more detail what is all included within a G0101- Breast and Pelvic Exam.
For starters, our physicians see quite a few Medicare patients for breast and pelvic exams and up to this point have been billing the G0101 only but also ordering mammograms, lab orders, and/or monitoring previous stable conditions.
I have tried doing quite a bit of research but unable to find an exact answer for this question through Medicare guidelines. Is anyone able to help with this?
Wondering- if it is okay to bill for E&M code in addition to G0101 when provider performs the above-mentioned services?

Thank you in advance!

 

[lgardner]

per CMS NCD on pap and pelvic:
A screening pelvic examination (including a clinical breast examination) should include at least seven of the following eleven 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
• _______________________________________

this is called the 7 out of 11 rule.
yes and E/M can be billed with G0101, but it only if there is a "separately and signaficantly identifiable service" above and beyond the p&p.

 

[csperoni]

I answered in your original post: https://www.aapc.com/discuss/threads/medicare-gyn-exam-g0101.191134/
For future reference, please post questions only once, it whatever forum you think is most appropriate. Posting duplicates creates issues like this where you wind up with 2 threads for the same question.

 

[smstearns]

per CMS NCD on pap and pelvic:
A screening pelvic examination (including a clinical breast examination) should include at least seven of the following eleven 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
• _______________________________________

this is called the 7 out of 11 rule.
yes and E/M can be billed with G0101, but it only if there is a "separately and significantly identifiable service" above and beyond the p&p.

How would you bill Medicare for a gyn annual exam? We are an ob/gyn office and our doctors don't do the personalized prevention plan of service included with G0438/G0439. They are still reviewing allergies, medications, social, surgical, ob/gyn & past medical history, ROS & a physical exam (including a pelvic exam) plus a pap and/or breast exam. Previously we had been advised to bill 99385-99387 or 99395-99397 plus G0101 if they had a breast exam and Q0091 if they have a pap. We then subtract the price of G0101 & Q0091 from the E/M code so the total is the same as a non-Medicare annual. Is this the correct way to bill it?
Thanks in advance!

 

[csperoni]

How would you bill Medicare for a gyn annual exam? We are an ob/gyn office and our doctors don't do the personalized prevention plan of service included with G0438/G0439. They are still reviewing allergies, medications, social, surgical, ob/gyn & past medical history, ROS & a physical exam (including a pelvic exam) plus a pap and/or breast exam. Previously we had been advised to bill 99385-99387 or 99395-99397 plus G0101 if they had a breast exam and Q0091 if they have a pap. We then subtract the price of G0101 & Q0091 from the E/M code so the total is the same as a non-Medicare annual. Is this the correct way to bill it?
Thanks in advance!

That is exactly correct. If the clinician provided a full preventive visit 9938x-9939x, that is what should be coded, even if not covered by carrier. The G0101 & Q0091 (if performed) are carved out of the preventive. I'm pretty sure @nielynco has posted comprehensive explanations and references for this in the past.