Document 7 of 11 Elements to Bill a Medicare Screening Pelvic Exam
I was recently asked about what needs to be documented to bill and get reimbursed for Medicare’s G0101, the Breast and Pelvic Exam that is part of the Well Woman Exam. Per the Centers for Medicare & Medicaid Services’ (CMS) document entitled, Screening Pelvic Examinations, on the Medicare Learning Network, G0101 is payable when at least 7 of the following 11 elements are included and documented in the exam.
Follow the G0101 documentation requirements listed below.
Documentation Guidelines for G0101
1. Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge
2. Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses
3. External genitalia (for example, general appearance, hair distribution, or lesions)
4. Urethral meatus (for example, size, location, lesions, or prolapse)
5. Urethra (for example, masses, tenderness, or scarring)
6. Bladder (for example, fullness, masses, or tenderness)
7. Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)
8. Cervix (for example, general appearance, lesions or discharge)
9. Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)
10. Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity)
11. Anus and perineum
The CMS material covers all the documentation elements needed, how frequently the exam can be done, co-insurance and deductible information, diagnosis requirements, and billing instructions. The document also includes reasons that the service may be denied. This is great information if you are doing medical billing for an OBGYN, Internal Medicine, or Family Practice. Note that even if you use Electronic Health Records (EHR), your templates may not be set up properly to capture all the data needed, so make sure you check it out.
I have yet to see an EMR set up properly out of the box. If you are still on paper, you may want to make a template for this screening procedure to make sure you don’t forget anything. To download the CMS Screening Pelvic Examinations August 2012 report CLICK HERE. Medicare requirements change all the time, so head over to the the CMS website for the most updated information on this topic. Oh, and don’t forget to have the patient sign an Advanced Beneficiary Notice (ABN).
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