G0123 — Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of SYMPTOMS OF VAGINITIS must be present to justify testing (e.g., abnormal vaginal discharge, vaginal odor, vaginal itch/irritation) — policy repeatedly specifies tests are medically necessary for women WITH SYMPTOMS OF VAGINITIS
- For Trichomonas screening, documentation of RISK FACTORS is required (examples listed: new or multiple sexual partners; history of sexually transmitted diseases; exchange of sex for payment; injection drug use)
- Appropriate ICD-10 diagnosis code from the policy's 'covered' list should be submitted with the claim (policy provides a list of covered ICD-10 codes such as A59.01, B37.31, B37.32, B96.89, N76.0–N76.3, N77.1, N89.8, O23.00–O23.93, L29.2, L29.3, Z72.51–Z72.53, etc.)
- Claims for PCR/molecular tests covered 'if selection criteria are met' — documentation must support that selection criteria (symptoms or risk factors as applicable) were met
Key Coverage Criteria
- Direct DNA probe assays (e.g., Affirm VP/VP III) for detection of Trichomonas vaginalis, Candida species, and Gardnerella vaginalis for members WITH SYMPTOMS OF VAGINITIS
- Measurement of sialidase activity in vaginal fluid (e.g., BVBlue test) for WOMEN WITH SYMPTOMS OF VAGINITIS
- Testing of vaginal pH and testing for presence of amines (e.g., FemExam) for WOMEN WITH SYMPTOMS OF VAGINITIS
- Nucleic acid amplification (PCR/NAAT) tests for diagnosis of bacterial vaginosis (examples: BD MAX Vaginal Panel, Aptima BV, NuSwab VG, OneSwab BV Panel PCR with Lactobacillus Profiling, SureSwab BV) in WOMEN WITH SYMPTOMS OF VAGINITIS
- Nucleic acid amplification (PCR/NAAT) tests for diagnosis of Candida vaginitis (detection of Candida albicans, glabrata, krusei, parapsilosis, tropicalis) in WOMEN WITH SYMPTOMS OF VAGINITIS (examples: BD MAX vaginitis panel, GenPath GenPap, INFINITI Candida Vaginosis QUAD Assay, LabCorp NuSwab, MDL OneSwab, Quest SureSwab)
- Screening for Trichomonas vaginalis with NAAT, direct probe, or antigen detection tests for WOMEN WITH RISK FACTORS (examples: new or multiple partners; history of sexually transmitted diseases; exchange of sex for payment; injection drug use)
4 Active Policies
CIGNA-A004 — Preventive Care Services - (A004)
AETNA-CPB-0327 — Infertility
AETNA-CPB-0643 — Diagnosis of Vaginitis
ANTHEM-CG-MED-53 — CG-MED-53 Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing
Related Codes
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