Question/confusion regarding the documentation of 7 of the 11 elements for the screening pelvic exam - G0101. I am new to billing these examinations.If the patient has had a hysterectomy and the documentation states "uterus - absent" does this count as an element or "uterus -absent cuff well supported"? I have found conflicting responses some saying yes it counts as an element or no it doesn't. Does anyone have any documentation with definite guidelines?
Also, if the provider does not assess the breast (due to patient being followed by a breast surgeon), can a G0101 be billed? I have read that the breast check HAD to be one of the elements? or is it ok to bill as long as there are 7 other elements?
Would rectovaginal exam count as 2 elements? If there is not 7 of the 11 elements, can it be billed as reduced services G0101-52?
Any information, documentation would be greatly appreciated!!
Thank you everyone
Becky