Primary Care Coding Alert

Despite rumors otherwise, you can use G0101 even when your FP doesn't perform a breast exam, thanks to a CMS myth-busting transmittal.

The myth: Before this confusing clarification, the definition of G0101 said pelvic and breast exam.-This inclusion, coupled with Medicare's arrangement of the code's required elements, led many coders to believe G0101 required a breast exam.

Now the breast exam is a parenthetical note, and the bullets are rearranged. The American College of Obstetricians and Gynecologists (ACOG) asked for the clarification because they do not believe a breast exam is necessary on every patient, especially if her PCP just did one.

The breast exam does not need to be one of the seven elements provided in a screening pelvic examination, according to CMS Transmittal 1541 (www.cms.hhs.gov/transmittals/downloads/R1541CP.pdf). It is one of 11 elements, "and only seven of those 11 elements need to be done and documented to claim G0101," explains Kent J. Moore, manager of the Health Care Financing and Delivery Systems for the American Academy of Family Physicians.

Previously, a note stating "should include at least seven of the following elements" preceded the screening pelvic examination's bulleted list in 100-4 Medicare Claims Processing Manual, Chapter 18, Section 40 (www.cms.hhs.gov/manuals/downloads/clm104c18.pdf). This organization, which listed the breast exam bullet as number one, caused the G0101 breast exam requirement myth.

Revised language adds "eleven" to the preceding note to read, "A screening pelvic examination with or without specimen collection for smears and cultures, 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 (for example, general appearance, hair distribution, or lesions)

- Urethral meatus (for example, size, location, lesions, or prolapse)

- Urethra (for example, masses, tenderness, or scarring)

- Bladder (for example, fullness, masses, or tenderness)

- Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)

- Cervix (for example, general appearance, lesions, or discharge)

- Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)

- Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity)

- Anus and perineum."

For coders who don't associate a breast exam with a screening pelvic examination, CMS added this reference. "Section 4102 of the Balanced Budget Act of 1997 (P.L. 105-33) amended -1861(nn) of the Act (42 USC 1395X(nn)) to include Medicare Part B coverage of screening pelvic examinations (including a clinical breast examination) for all female beneficiaries for services provided Jan. 1, 1998 and later," indicates MLN Matters article MM6085 (www.noridianmedicare.com/provider/updates/docs/MM6085_Screening_Pelvic.pdf). "The parenthetical makes it clear that Medicare coverage of a clinical breast exam is included in Medicare coverage of a screening pelvic exam," Moore says.

The parenthetical inclusion, however, does not mean a screening pelvic examination must include a clinical breast examination. The revisions mean Medicare "allows a screening pelvic exam to include a breast exam or not at the performer's discretion," says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president, ProActive Consultants in Cumberland, Wis.

Bottom line: "The breast exam is included if done, but it is not required to be done to claim G0101," Moore says. To use a restaurant analogy, it's like saying the eggs are included in the breakfast buffet, but you don't have to get the eggs if you get the buffet.