Overview
HCPCS Code G0101 is used to report a screening pelvic examination and clinical breast examination performed for the early detection of cervical or vaginal cancer in Medicare beneficiaries. This preventive service includes a comprehensive evaluation of the external genitalia, pelvic organs, and breasts as part of routine cancer screening.
G0101 is a Medicare-covered preventive service when eligibility requirements are met. It is not a diagnostic exam and does not include treatment of abnormalities unless separately billed and documented.
Key Facts About G0101
- Service type: Medicare preventive screening service
- Provider type: Physicians and qualified healthcare professionals
- Medical services included:
- Pelvic examination
- Clinical breast examination
- Screening for cervical or vaginal cancer
- Patient population: Medicare beneficiaries
- Frequency:
- Once every 24 months for most patients
- Once every 12 months for high-risk patients or those of childbearing age with abnormal Pap history
- Common clinical indications:
- Routine cancer screening
- High-risk cervical or vaginal cancer monitoring
- Preventive women’s health evaluation
When to Use G0101
G0101 is appropriate when:
- The visit is performed solely for screening purposes
- The patient meets Medicare eligibility criteria
- The service includes both a pelvic exam and clinical breast exam
- No diagnostic evaluation is the primary reason for the visit
Examples:
- Routine Medicare-covered pelvic and breast screening exam
- Annual screening for a high-risk Medicare beneficiary
- Preventive women’s health visit focused on cancer screening
Documentation Requirements
To properly support G0101 billing, documentation should include:
- Confirmation of Medicare eligibility and screening frequency
- Pelvic examination findings
- Clinical breast examination findings
- Assessment of cancer risk factors
- Preventive counseling and follow-up recommendations
If diagnostic findings are identified and addressed, documentation must clearly separate screening services from problem-oriented evaluation and management.
Reimbursement and Coding Considerations
- G0101 is covered 100% by Medicare when eligibility and frequency rules are met
- The service is not subject to deductible or coinsurance
- Diagnostic E/M services may be billed separately when medically necessary
- Additional tests (e.g., Pap tests) are billed using separate codes
- Providers should verify Medicare guidelines for high-risk eligibility
How OptiMantra Supports Preventive Women’s Health Services
OptiMantra’s integrated EMR and practice management platform streamlines documentation and billing for Medicare preventive services such as G0101.
With OptiMantra, providers can:
- Use structured templates for pelvic and clinical breast exams
- Track Medicare screening eligibility and frequency automatically
- Clearly separate preventive and diagnostic services in the chart
- Generate compliant, audit-ready Medicare claims
- Integrate screening results into long-term preventive care plans
By centralizing preventive care workflows and documentation, OptiMantra helps practices deliver high-quality women’s health services while maintaining Medicare compliance.
Try OptiMantra for free here!
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