g0101 billing guidelines

(2022) CPT G0101 & CPT Q0091 – Descriptions, Billing Guidelines & Reimbursement

The Centers for Medicare & Medicaid Services (CMS) has determined that CPT G0101 billing guidelines (Cervical cancer screening; pelvic and clinical breast examination) and CPT Q0091 (screening Papanicolaou smear) are billable visits when furnished by a RHC or FQHC practitioner to a RHC or FQHC patient.

CPT G0101

Description Of CPT G0101

Cervical or other cancer of the female genitalia screening; pelvic and clinical breast examination.

CPT G0101 Requirements

7 of the 11 exam elements are required.

  • Pelvic exam including;
    • Rectal passage and perineum;
    • Adnexa/parametria;
    • Uterus;
    • Cervix;
    • Female genitalia;
    • Urethra;
    • Bladder;
    • External genitalia;
    • Urethral meatus;
  • Digital rectal exam
  • Inspection and palpation of the breasts for lumps, tenderness, symmetry or nipple discharge

CPT Q0091

Description of CPT Q0091: Screening Papanicolaou smear; obtaining, preparing and coveyance or cervical or genitalia smear to laboratory.

Coding Guidelines For CPT G0101 & CPT Q0091

CR8927 instructs MACs to allow CPT G0101 and CPT Q0091 to be billed as a standalone encounter/visit.

These services will be paid the AIR on RHC and FQHC claims for 71X and 77X Types of Bills (TOBs), effective for dates of service on or after January 1, 2014. Please note that deductible and coinsurance are NOT to be applied to CPT G0101 or CPT Q0091.

If other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid.

Reimbursement For CPT G0101 & CPT Q0091

CPT G0101 or CPT Q0091 are payable annually for women at high risk for developing cervical or cancer of female genitalia, and women of childbearing age who have had an abnormal Pap test within the past 3 years.

It is payable every 2 years for women at normal risk. For FQHCs billing under the PPS, CPT G0101 and CPT Q0091 are qualifying visits when billed with FQHC payment HCPCS codes G0466 or G0467.

Last Node

MAC will not search for claims that have been denied with CPT G0101 billing guidelines or CPT Q0091 prior to the implementation of CR8927, but will adjust any claims that you bring to their attention.

Reference for CPT G0101 & CPT Q0091: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8927.pdf

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