Summary & Overview
HCPCS Level II S0613: Annual Gynecological Exam, Clinical Breast Exam Only
HCPCS Level II code S0613 denotes an annual gynecological visit limited to a clinical breast examination without a pelvic evaluation. This code captures a focused preventive service commonly used in office-based gynecology and primary care to assess breast health, perform clinical palpation, and document findings for routine screening and risk discussion. Nationally, accurate use of S0613 affects preventive care reporting, encounter documentation, and payer coverage determinations for women’s health services.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find concise guidance on the clinical context for the code, typical sites of service, and what to expect in payer coverage and billing practice patterns. The publication outlines common documentation elements, benchmark considerations for preventive visits, and policy updates that influence coding for breast-only gynecologic evaluations.
The report is written for a national audience and provides benchmarks, coding guidance, and policy context to help clinicians, billing teams, and administrators understand when S0613 is appropriate, how it differs from comprehensive gynecologic exams, and which payer categories commonly reimburse this focused preventive service. Data not available in the input will be identified where applicable in deeper sections.
Billing Code Overview
HCPCS Level II code S0613 represents an annual gynecological examination consisting of a clinical breast examination without pelvic evaluation. This service is typically rendered as a preventive or routine office-based gynecologic encounter focused on breast health assessment and screening discussion. The service type is a preventive gynecologic exam (clinical breast exam only). The typical site of service is an outpatient physician office or clinic.
Clinical & Coding Specifications
Clinical Context
A 42-year-old woman presents to an outpatient gynecology clinic for her annual gynecological examination. She reports no pelvic pain, abnormal vaginal bleeding, or discharge but requests routine preventive care. The visit includes a focused history (menstrual history, contraception, sexual health, breast symptoms), a screening clinical breast examination, and counseling on breast self-awareness and preventive care. No pelvic examination, Pap test, or pelvic procedures are performed. Vital signs are recorded, and risk factors such as family history of breast cancer and recent imaging are reviewed. If an abnormality is found on breast exam, the clinician documents findings and arranges appropriate diagnostic follow-up (diagnostic imaging or referral). Typical workflow: check-in and insurance verification, review of systems and focused history by medical assistant or nurse, clinician visit performing the clinical breast exam and counseling, documentation of exam findings and plan, scheduling of any follow-up imaging or specialist referral, and check-out. Typical site of service is outpatient clinic or physician office focused on preventive gynecologic care. The service corresponds to an annual gynecological examination limited to a clinical breast examination without pelvic evaluation and is billed with code S0613.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure |