Medicare guidelines for well women examination

MEDICARE- G0101 & Q0091

Covered Services

---

Medicare covers the following screening exams along with a Well Woman Exam:

1. G0101 (Cervical or Vaginal Cancer Screening; Pelvic and Clinic Breast Examination):

a. G0101 is reimbursed by Medicare every two years, unless the patient is considered high risk, and then it is allowed on an annual basis.

2. Q0091 (Screening Papanicolaou Smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) :

a. Q0091 is reimbursed by Medicare every two years, unless the patient is considered high risk, and then it is allowed on an annual visit.

C. As per the CMS website the ICD-10-CM codes billable with the Q0091 are Z12.4,Z12.72,Z12.79,Z12.89 and Z01.411,Z01.419.

3. 82270 (Fecal Occult Blood Test) :

a. 82270 can be billed on an annual basis.
b. Per the CMS website, the appropriate code varies by carrier. An applicable code is Z12.11 Special Screening for Malignant Neoplasms; Colon.

High Risk Factors and Frequency:

 If a patient is considered high risk, then these screening tests might have done annually.

According to the CMS, the following below are listed as high risk factors for screening pap smears and pelvic exams

1.      Cervical High Risk Factors
a. Early onset of sexual activity (under 16 years of age)
b. Multiple (five or more in a lifetime) sexual partners 
c. History of a sexually transmitted disease (including HIV,HPV infection)
d. Fewer than 3 negative or any Pap smears within previous 7 years

2.      Vaginal Cancer High Risk Factors: DES (diethylstilbestrol) exposed daughters of women who took DES during pregnancy.

3.      Personal Hx of Health Hazards:

       If a patient has a specified personal history presenting hazards to health then apply the V15.89 diagnosis and the appropriate health history hazard (example: V10.3 History of Breast Malignancy). Any V15.89 diagnosis is considered high risk and makes the patient eligible for the yearly G0101 and Q0091

b. According the CMS website: The below given diagnose codes are appropriate to bill the CPT® G0101

Select the appropriate ICD10 codes : Z12.4,Z12.72,Z12.79,Z12.89 and Z01.411,Z01.419.

i.   Special screening for malignant neoplasms, cervix
ii.  Special screening for malignant neoplasms, vagina
iii. Special screening for malignant neoplasms, other sites
iv. Other specified personal history presenting hazards to health
v.  Routine gynecological exam