Coding information about physical exams for Medicare Advantage members

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Coding information about physical exams for Medicare Advantage members


In 2020, obstetricians and gynecologists seeing a ConnectiCare Medicare Advantage member should only perform and bill the Medicare-covered annual pap/pelvic exam. Obstetricians and gynecologists should refer patients to their primary care providers (PCPs) for the preventive annual physical exam.

On and after Jan. 1, 2020, ConnectiCare will only cover CPT codes from 99381 through 99397 if the services were performed by PCPs. Ob/gyns will only be reimbursed for CPT code G0101 to stay consistent with reimbursement guidelines of the Centers for Medicare & Medicaid Services.

Here are some details about the G0101 submission code for pap/pelvic exam and pap collection:

  • You may bill a separate E/M (evaluation and management) code only if you provided a separately identifiable E/M service
  • $0 in-network
  • A copay or co-insurance may apply if a member uses an out-of-network benefit, if available
  • Every calendar year for those at high risk (visits do not need to be 12 months apart)
  • Every two calendar years for women not considered high risk (visits do not need to be 24 months apart)

A well-woman exam should include at least seven of the following criteria:

  1. Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge
  2. Digital rectal examination including sphincter tone and presence of hemorrhoids or rectal masses
  3. Examination of external genitalia: for example, general appearance, hair distribution or lesions
  4. Examination of urethral meatus: for example, size, location, lesions or prolapse
  5. Examination of urethra: for example, masses, tenderness or scarring
  6. Examination of bladder: for example, fullness, masses or tenderness
  7. Examination of vagina: for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele or rectocele
  8. Examination of cervix: for example, general appearance, lesions or discharge
  9. Specimen collection for Pap smears and cultures