11 Documentation Elements for Medicare G0101

Health Insurance Companies Process 1 in 5 Claims Wrong

Document 7 of 11 Elements to Bill a Medicare Screening Pelvic Exam

Medicare G0101 Screening Pelvic ExaminationsI 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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15 Responses to “11 Documentation Elements for Medicare G0101”

  1. Thanks for the breakdown of billing for impacted cerumen, I was aware of some of the criteria but your explanation really gives me a clinical picture.

  2. Coding for G0101 (Medicare Screening Pelvic/Breast Exam) is pretty straightforward. Where I struggle is when the documentation includes a comprehensive exam, discussion of vaccine, Dexa, ADL’s etc. and begins to look more like a preventive exam. I.e. 99397 which is we all know is not payable by Medicare. I cannot find anything guidelines or discussion regarding this. How would code an encounter like this?

    Thank you,

    • CarolAnn —

      Well if it meets all the requirements of a 99397 I would bill the patient for the preventative exam carving out the Medicare reimbursements for the G0101 and Q0091 if done. We do bill the 99397 to Medicare to get the denial to try to have secondary pay, which some do although not many.

      • Manny

        My mother is 65 years plus and received an annual screening examine which they billed to Medicare under code 99397 which is not reimbursable under Medicare. My mother has been receiving these exams annually. Shouldn’t her physician office bill these claims with G0101 and attached the medical records indicating 7 of the 11 criteria so they will pay anally. Now they are trying to bill my mother.


  3. Do you mind if I quote a couple of your articles as long as I provide credit and sources back to your weblog? My website is in the very same area of interest as yours and my users would definitely benefit from some of the information you provide here. Please let me know if this alright with you. Many thanks!

    • Taryn —

      No problem quoting parts of a post, just not the whole post. Please use proper arbitration crediting me and Capture Billing as the source of the quote.


  4. Hi Manny

    How do I bill for consult palliative care in hospital? I normally add in modify for hospice pt as GV or GW. Do I need something like that for palliative care?


    PS: Do you have any training class for billing or coding?

  5. Hello, We at our practice have noticed that CMS has added to Cerumen removal code. We are having a really hard time getting our physicians to document this correctly. They all want to bill the code documenting only Lavage. It is our practice that this would be included in the E/M service. Could you elaborate on the proper way to bill for an OV and the Removal?

    • Yolanda —

      Medicare will not cover simple, non-impacted earwax removal. This is included in the E/M service.

      Medicare requires that providers meet the following criteria for reimbursement of the removal of impacted cerumen:

      1. The procedure is the sole reason for the patient encounter;
      2. A physician or non-physician (nurse practitioner, physician assistants, or clinical nurse specialist) carries out the treatment.
      3. The patient in question is symptomatic; and
      4. The supporting documentation shows significant time and effort spent performing the service.

      Furthermore, for Medicare reimbursement of an E/M visit and cerumen removal, the following criteria must be met:

      1. The initial reason for the patient’s visit was separate from the cerumen removal.
      2. Otoscopic examination of the tympanic membrane is not possible due to the impaction;
      3. Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner and is personally performed by him or her; and
      4. The procedure requires a significant amount of time and effort, and all of the above criteria are clearly documented in the patient’s medical record.

      • Thank you Manny for your response. It’s technical in which I clearly understand it. My physicians will not get this. Is it possible to eloborate what the physician must say in order for them to bill. We have told them that a Lavage is not acceptable and that we will not bill the cerumen to the Insurance Companies. I can assure you that these patients are not being seen for the impaction, but for other issues in which the impaction arise once the patient is in the office. It has become such an issue now that CMS has added the 50 modifier. Your help is greatly appreciated. We have a compliance officer, who tries her best, she is not always clear on her description to the physicians nor the billers.

        • OK Yolanda lets see if I can help more.

          First of all let’s define impacted cerumen. Cerumen is considered impacted if at least one of the following is present:

          Visual: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane or middle ear condition.

          Qualitative: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.

          Inflammatory: Associated with foul odor, infection or dermatitis.

          Quantitative: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.

          The physician should document the following:
          1. Conditions present
          2. Reason for procedure
          3. Difficulty
          4. Method of removal (otoscope and wax curetts, forceps and/or suction)
          5. Extent of procedure and work involved including time.

          Per CMS if you use softening drops, cotton swabs, lavage and/or cerumen spoon the procedure is considered incidental and cannot be billed separately. Individual commercial insurance companies may have their own criteria so you may want to check if it differs a bit from CMS.

          Does this help?



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