The American Congress of Obstetricians and Gynecologists (ACOG) reports that some Medicare contractors are refusing to provide payment for routine pelvic and breast examinations when they are reported using HCPCS Level II code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). To be very specific, the payment is denied when the medical documentation prepared for medical billing contains the notation of surgically absent organs as part of the seven of eleven necessary exam components.

As per the Centers for Medicare and Medicaid Services, G0101 is payable under Medicare physician fee schedule only if at least seven elements from the following are included in the exam.

  • Adnexa/parametria (for example, masses, tenderness, organomegaly or nodularity)
  • Anus and perineum
  • Bladder (for example, fullness, masses, or tenderness)
  • Cervix (for example, general appearance, lesions or discharge)
  • Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses
  • External genitalia (for example, general appearance, hair distribution, or lesions)
  • Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge
  • Urethra (for example, masses, tenderness, or scarring)
  • Urethral meatus (for example, size, location, lesions, or prolapse)
  • Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)
  • Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)

Once the ACOG Health Economics and Coding Committee reviewed the issue of claim denial, they determined G0101 should be covered even if the documentation reports the absence of the breast(s), cervix, uterus, fallopian tube(s), and/or ovary(s).

Major Reasons for G0101 Claim Denials

According to the AAPC, there are mainly three reasons for G0101 claim denials such as

  • Timing – Medicare Part B covers screening pelvic examination every 24 months (at least 23 months since the most recent screening pelvic exam) or every 12 months (at least 11 months since the most recent screening pelvic exam) for asymptomatic female beneficiaries if they are at high risk for developing cervical/vaginal cancer, or of childbearing age and have had a pelvic exam in the last three years which indicated the occurrence of cervical/vaginal cancer or other abnormality.
  • Medical Necessity – If the timing is correct, the problem may be with the diagnosis that indicates medical necessity. You may have assigned the wrong diagnosis code for the relevant procedure. A few ICD-9-CM diagnosis codes are there that indicate a screening pelvic exam for a low-risk patient (for example, V72.31 routine gynecological examination). But if the documentation states the patient is without a cervix, the correct code to indicate that is V76.49 Special screening for malignant neoplasms, other sites.
  • Place of Service – If your claim is not denied due to the above two reasons, check whether you have assigned the appropriate place of service code. This code should be included on the medical claim to specify the place where the service was provided.

You can find the entire Place of Service code set on the official website of the Centers for Medicare and Medicaid Services. Some of them are given below.

  • 21 – Inpatient Hospital (A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions)
  • 22 – Outpatient Hospital (A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization)
  • 23 – Emergency Room – Hospital (A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided)
  • 24 – Ambulatory Surgical Center (A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis)

By partnering with a professional medical billing and coding company, you can reduce costly coding mistakes and documentation errors to a great extent. Such a company will provide the service of experienced AAPC certified coders and conduct frequent audits to identify coding errors.