CMS Pub. 100-04, ch. 18, § 40.6

A. Billing to the A/B MAC (B)

Code G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination) is used.

Effective for services on or after January 1, 1999, a covered evaluation and management (E/M)

visit and code G0101 may be reported by the same physician for the same date of service if the

E/M visit is for a separately identifiable service. In this case, the modifier “-25” must be reported

with the E/M service and the medical records must clearly document the E/M service reported.

Both procedure codes should be shown as separate line items on the claim. These services can also

be performed separately on separate office visits.

B. Billing to the A/B MAC (A)

The applicable bill types for a screening pelvic examination (including breast examination) are

12X, 13X, 22X, 23X, and 85X. The applicable revenue code is 0770. (See §70.1.1.2 for RHCs

and FQHCs.) Effective April 1, 2006, type of bill 14X is for non-patient laboratory specimens and

is no longer applicable for a screening pelvic examination.

The professional component of a screening pelvic examination furnished within an RHC/FQHC by

a physician or nonphysician is considered an RHC/FQHC service. RHCs and FQHCs bill the A/B

MAC (A) under bill type 71X or 73X for the professional component along with revenue code

052X.

The technical component of a screening pelvic examination is outside the scope of the RHC/FQHC

benefit. If the technical component of this service is furnished within an independent RHC or

freestanding FQHC, the provider of that technical service bills the A/B MAC (B) on the ASC X12

837 professional claim format or hardcopy Form CMS-1500.

If the technical component of a screening pelvic examination is furnished within a provider-based

RHC/FQHC, the provider of that service bills the A/B MAC (A) under bill type 12X, 13X, 22X,

23X, or 85X as appropriate using their outpatient provider number (not the RHC/FQHC provider

number since these services are not covered as RHC/FQHC services). The appropriate revenue

code is 0770. Effective April 1, 2006, type of bill 14X is for non-patient laboratory specimens and

is no longer applicable for a screening pelvic examination.