Medicare covers screening pelvic and clinical breast exams using G0101, but the frequency limits depend entirely on the patient's risk factors.
Frequency: High Risk vs Low Risk
If the patient is considered "low risk," Medicare covers G0101 once every 24 months. If the patient is considered "high risk" (e.g., history of cervical cancer, early onset of sexual activity), Medicare covers it once every 12 months.
Medical Necessity: The 7 Elements
To bill G0101, the exam must include at least 7 of the following 11 elements: Inspection/palpation of breasts, digital rectal exam, pelvic exam (external genitalia, urethral meatus, urethra, bladder, vagina, cervix, uterus, adnexa/parametria, anus/perineum). Diagnosis code Z01.419 is commonly used.
NCCI Edits and Q0091
G0101 is almost always billed alongside Q0091 (Obtaining screen pap smear). They are separate services and do not bundle into each other.