Rectal examinations (digital or with the use of a proctoscope) can be performed on patients with no signs or symptoms of disease, and on symptomatic patients to aid in diagnosis or treatment. Rectal examinations performed on asymptomatic patients are considered to be screening.  Coverage for screening rectal examinations is determined according to individual or group customer benefits.

The following codes may be reported for screening rectal examinations:

• G0102 - Prostate cancer screening; digital rectal examination

  G0102 represents a clinical examination of an individual's prostate for nodules or other abnormalities of the prostate.

• S0605 - Digital rectal examination; annual

  S0605 represents a clinical examination of the rectum and is not specific to a male patient or the prostate.

• S0601 - Screening proctoscopy

  S0601 represents an examination of the rectum with a proctoscope.

When a benefit, a screening rectal examination (G0102, S0605, S0601) is considered to be part of a covered evaluation and management service or gynecological examination (S0610-S0612). Therefore, when a covered screening rectal examination is reported on the same day as a covered evaluation and management service or gynecological examination, combine the charges for the rectal examination with the charges for the evaluation and management service or gynecological examination and pay only the evaluation and management service or gynecological examination. Payment for the evaluation and management service or gynecological examination includes the allowance for the rectal examination. A participating, preferred, or network provider cannot bill the patient separately for the rectal examination in this case. However, when a covered screening rectal examination is performed independently, it may be paid.

Rectal examinations or proctoscopies performed on symptomatic patients are considered an integral part of a doctor’s medical care.  If rectal examinations or proctoscopies are reported on the same day as a medical care, and the charges are itemized, combine the charges and pay only the medical care.  Payment for the medical care performed on the same date of service includes the allowance for the rectal examinations or proctoscopies.  A participating, preferred, or network provider cannot bill the member separately for the rectal examinations or proctoscopies in this case.

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the rectal examinations or proctoscopies or gynecological examinations.  When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.