Preventive Services

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

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

Related Content

Reviewed 10/12/2023