Preventive Services Guide

Screening Pelvic Examination

A pelvic examination is a type of gynecologic examination for women. Some of the conditions that health care providers look for during a pelvic examination include infections, fibroids, cervical polyps and ovarian cysts.

Coverage Criteria

The screening pelvic examination includes a clinical breast examination.

Covered every 24 months for asymptomatic non-high-risk female patients.

Covered every 12 months when one criteria is met:

Evidence of high risk
Examination indicated cervical/vaginal cancer or other abnormality during any of preceding three years for woman of childbearing age

Cervical/vaginal high-risk factors include the following:

Early onset of sexual activity (aged 16 and younger)
Multiple sexual partners (five + in lifetime)
History of a sexually transmitted disease
- Includes HPV and/or HIV infection
Fewer than three negative pap tests of no pap test within previous seven years
Diethylstilbestrol (DES) exposed daughters of women who took DES during pregnancy

Screening pelvic exam elements 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
External genitalia
- general appearance, hair distribution, lesions
Urethral meatus
- Size, location, lesions, prolapse
Urethra
- Masses, tenderness, scarring
Bladder
- Fullness, masses, tenderness
Vagina
- General appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele
Cervix
- General appearance, lesions, discharge
Uterus
- Size, contour, position, mobility, tenderness, consistency, descent, support
Adnexa/parametria
- Masses, tenderness, organomegaly, nodularity
Anus and perineum

Pelvic Exam Procedure/HCPCS Code

G0101: Cervical or vaginal cancer screening; pelvic and clinical breast examination

Diagnosis Coding

ICD-10 Codes:

High risk – Z72.51, Z72.52, Z72.53, Z77.29, Z77.9, Z91.89 and Z92.89
- Code Z77.22 changed to Z77.29
- Code Z72.89 changed to Z92.89
Low risk – Z01.411, Z01.419, Z12.4, Z12.72, Z12.79 and Z12.89

Current codes are listed in the ICD-10 Conversion/Coding Infrastructure Revisions to National Coverage Determinations (NCDs)-3rd Maintenance CR9252. The CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 40.4 is pending an update to correct this information.

Additional ICD-10 codes may apply. See the CMS ICD-10 webpage for individual CRs and the specific ICD-10-CM codes Medicare covers for this service and contact your Medicare Administrative Contractor (MAC) for guidance.

Who Can Perform?

Must be ordered and collected by DM, DO or other qualified NPP
Must be authorized under state law to perform
Qualified NPPs including certified nurse midwife, physician assistant, nurse practitioner and clinical nurse specialist

Cost Sharing

Copayment/coinsurance waived
Deductible waived

Reimbursement

MPFS: Fee Schedule Lookup

Nonparticipating Providers

Nonparticipating reduction applies
Limiting charge provision applies

Billing Tips

Screening pelvic examination and screening pap test can be performed during the same encounter
- Enter both procedure codes on separate line items of the claim

Common Claim Denials

Patient not at high risk and received covered screening within past two years
High-risk patient received covered screening within past year