• Medicare developed two HCPCS codes for screening services for women, without definitive frequency time limits
• Both G0101 (screening breast and pelvic exam) and Q0091 (obtaining a screening pap smear) may be billed every two years for a low-risk patient and every year for high-risk patients
• These are not comprehensive preventive medicine services
• They may be billed on the day of a covered service (wellness visit, or a separate, problem-oriented visit) or of a non-covered service (routine preventive care codes 99381-99397, considered routine by original Medicare)
• Medicare Advantage plans can set their own rules about covered preventive services
• Information about code +99459 pelvic examination is added to the end of this article

Original Medicare does not pay for annual routine physical exams – 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 pays for annual screening pelvic and breast exams,

• 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.

Report this service with code G0101.

Medicare 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

There is a list of high risk and low risk diagnosis codes in the video. The video was recorded in 2020, and note that there are additional high risk diagnosis codes that are not on the slide highlighting diagnosis codes. These are: Z92.850, Z92.858, Z92.86, Z92.89 (descriptions below.)

+99459 Pelvic examination

CPT® introduced this code in 2024 as an add-on code to new and established patient visit codes  99202–99205, 99212–99215, consultation codes 99242–99245 and preventive medicine codes. 99383–99387, 99393–99397. It is an active code in the physician fee schedule, without wRVUs. (It is to cover the practice expense for performing a pelvic exam. When the AMA’s RVS Update Committee  (RUC) values practice expense codes they include both staff time and supplies. This code is valued with 4 minutes of staff time and a supply kit of $20. That doesn’t mean you’ll get paid $20 outright, but that is the national cost built into valuing the code.)

At the 2024 AMA CPT symposium, the Q&A included this question: Is a chaperone required in order to report add-on code 99459? Their answer is no. They state that 99459 was developed to capture additional practice resources needed when a pelvic exam is performed, pointing out that the code is a practice expense only code. They state that while the valuation includes a chaperone, it is not required to report the code. This makes sense, because in addition to staff expense, a pelvic exam has supply expense.

. We know that there is also additional staff time in setting up the room for a pelvic, and if a pap is done, for preparing and transmitting the specimen.  The total RVUs in both a facility and non-facility are .68, so the national reimbursement with a conversion factor of $32.74 is about $22.26.

• Use the code for both preventive and problem visits
• Neither CPT®, nor CMS in the Final Rule mention diagnosis coding, but our advice is to use  the code for the primary E/M procedure (which you are affixing a modifier 25 to)

Here is a link to the CMS preventive tool about this screening.

https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-1.html#PELVIC

Members login to access Betsy’s video review of G0101 and  Q0091.

Pelvic/breast exam G0101 requires 7 of 11 exam elements

Our interpretation is that examination of the breast is mandatory to bill G0101, although other consultants interpret this differently.

• Inspection and palpation of the breasts for lumps, tenderness, symmetry or nipple discharge
• Digital rectal exam
• Pelvic exam including:
  • External genitalia
  • Urethral meatus
  • Bladder
  • Urethra
  • Vagina
  • Cervix
  • Uterus
  • Adnexa/parametria
  • 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

High risk:

• 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

Low Risk:

• 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

Related Resources

• Preventive Services/Medicare
• Billing for pap smear