The documentation might reflect Medicare code of G0101 as in order to bill G0101 (Cervical or vagiinal cancer screening; pelvic and breast examination)
screening pelvic examination (HCPCS code G0101) should include documentation of at least seven of the following eleven elements:
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)
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9. Uterus (for example, size, contour, position, mobility, tenderness, consistency,
descent, or support)
10. Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity) and/or
11. Anus and perineum
HCPCS code G0101 includes only the above examination elements. It does not include the many other services normally included in a comprehensive preventive visit.
hope this helps?