CMS Pub. 100-04, ch. 18, § 40.1

2001

(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)

B3-4603.2.A, B3-4603.5, A3-3628.1.B.1, R1888.A.3 Dated 6-3-2003

The following requirements must be met.

The exam must be performed by a doctor of medicine or osteopathy (as defined in §1861(r)(1) of

the Act), or by a certified nurse midwife (as defined in §1861(gg) of the Act), or a physician

assistant, nurse practitioner, or clinical nurse specialist (as defined in §1861(aa) of the Act) who is

authorized under State law to perform the examination. This examination does not have to be

ordered by a physician or other authorized practitioner.

Payment may be made: Once every three years on an asymptomatic woman only if the individual

has not had a screening pelvic examination paid for by Medicare during the preceding 35 months

following the month in which the last Medicare-covered screening pelvic examination was

performed. Providers use ICD-10-CM codes for the low risk factors. Exceptions are as follows:

• Payment may be made for a screening pelvic examination performed more frequently

than once every 35 months if the test is performed by a physician or other practitioner

and there is evidence that the woman is at high risk (on the basis of her medical history

or other findings) of developing cervical cancer, or vaginal cancer. Providers use ICD-

10-CM codes for the high risk factors for cervical and vaginal cancer are:

Cervical Cancer High Risk Factors

• Early onset of sexual activity (under 16 years of age)

• Multiple sexual partners (five or more in a lifetime)

• History of a sexually transmitted disease (including HIV infection)

• Fewer than three negative or any Pap smears within the previous seven years

Vaginal Cancer High Risk Factors

• DES (diethylstilbestrol)-exposed daughters of women who took DES during

pregnancy.

ICD-10-CM code Z92.89, Personal history of other medical treatment is used to indicate

that one or more of these factors is present; or

• Payment may also be made for a screening pelvic examination performed more frequently

than once every 36 months if the examination is performed by a physician or other practitioner,

for a woman of childbearing age, who has had such an examination that indicated the presence of

cervical or vaginal cancer or other abnormality during any of the preceding three years. The term

“women of childbearing age” means a woman who is premenopausal, and has been determined

by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or

other findings. Payment is not made for a screening pelvic examination for women at high risk or

who qualify for coverage under the childbearing provision more frequently than once every 11

months after the month that the last screening pelvic examination covered by Medicare was

performed.

• For claims with dates of service on or after July 1, 2001, if the beneficiary does not qualify

for an annual screening pelvic exam as noted above, pay for the screening pelvic exam only after

at least 23 months have passed following the month during which the beneficiary received her last

covered screening pelvic exam. All other coverage and payment requirements remain the same.

Calculating the Frequency Limitations

To determine the screening periods, start counts beginning with the month after the month in which

a previous test/procedure was performed.

Frequency Limitation Example

A beneficiary identified as being at high risk for developing cervical cancer received a pelvic

exam in January 2002. Start counts beginning with February 2002. The beneficiary is eligible to

receive another screening exam, if high risk, in January 2003 (the month after 11 full months have

passed).