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Payment for HCPCS codes G0101, G0102 and E & M services on the same day

HCPCS code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) may be reported with evaluation and management (E&M) services under certain circumstances.  If a Medicare covered reasonable and medically necessary E&M service requires breast and pelvic examination, HCPCS code G0101 should not be additionally reported.  However, if the Medicare covered reasonable and medically necessary E&M service and the screening service, G0101, are unrelated to one another, both HCPCS code G0101 and the E&M service may be reported appending modifier 25 to the E&M service CPT code.  Use of modifier 25 indicates that the E&M service is significant and separately identifiable from the screening service, G0101.

HCPCS code G0102 (Prostate cancer screening; digital rectal examination) is not separately payable with an evaluation and management code (CPT codes 99201-99499).  CMS published this policy in the Federal Register, November 2, 1999, page 59414 as follows:

“As stated in the July 1999 proposed rule, a digital rectal exam (DRE) is a very quick and simple examination taking only a few seconds.  We believe it is rarely the sole reason for a physician encounter and is usually part of an E/M encounter.  In those instances when it is the only service furnished or it is furnished as part of an otherwise non-covered service, we will pay separately for code G0102.  In those instances when it is furnished on the same day as a covered E/M service, we believe it is appropriate to bundle it into the payment for the covered E/M encounter.”

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