HCPCS code S0613: Annual gynecological exam without pelvic evaluation

Key takeaways

HCPCS code S0613 covers an annual gynecological examination with a clinical breast examination but no pelvic evaluation. Its short descriptor is Ann breast exam.

S0610 and S0612 differ only by patient status. S0610 covers a new patient and S0612 covers an established patient, and neither describes a more comprehensive exam.

S0613 is the only code in this family defined by what was examined. It has no new-patient or established-patient version.

There is no HCPCS code S0614. The official S-code sequence runs from S0613 straight to S0618, an unrelated audiometry code.

Medicare never pays S0613, because CMS flags S-codes as not payable. Verify state Medicaid and commercial coverage before you submit a claim.

Practice management software like Pabau supports S-code billing, so you can attach the right diagnosis pairings and submit clean preventive care claims.

The official long descriptor for HCPCS code S0613 is: Annual gynecological examination; clinical breast examination without pelvic evaluation. The short descriptor is Ann breast exam. It sits in the temporary HCPCS Level II S-code range published by the Centers for Medicare and Medicaid Services (CMS). The code took effect on July 1, 2005.

S-codes are temporary HCPCS Level II codes. The Blue Cross Blue Shield Association and the Health Insurance Association of America created them for private payer use. They describe services and supplies that CPT does not list. State Medicaid agencies later adopted many of them, which is why S0613 turns up on Medicaid fee schedules but never pays under Medicare.

HCPCS Level II mixes permanent code ranges with temporary ones, and payment rules follow the range. Permanent codes, such as the J-codes used for drugs like J1410, apply nationally across payers. The temporary ranges are much narrower in scope. C-codes such as C1764 exist for hospital outpatient billing, and the S-codes exist for private payers.

S0613 inherits the payment rules of the S-code range, whatever the visit itself involved. Billers at OB/GYN practices with a mixed payer population should confirm each patient’s primary coverage before choosing this code.

S0613 vs. S0612 vs. S0610: How the annual gynecological exam codes differ

Two different variables separate the three annual gynecological examination S-codes. S0610 and S0612 are split by patient status. S0613 is split by what the provider examined. Treating all three as one sliding scale is the leading cause of denials in this family.

None of the three descriptors ranks the exam by comprehensiveness. That misreading leads billers to choose a code by how thorough the visit felt. The descriptors turn on two facts instead. Those facts are the patient’s status and the content of the exam.

S0610 and S0612 carry identical descriptors apart from the last two words. The only question they ask is whether the patient is new or established. Payers generally borrow the CPT definition of a new patient. A patient with no face-to-face service from the practice in three years counts as new. Comprehensiveness never enters the choice.

S0613 turns on the second variable. Its descriptor names the service content, so it applies when the provider performed a clinical breast examination and did not perform a pelvic evaluation. S0613 has no new-patient or established-patient version, so patient status cannot be signaled through the code itself. Check the payer’s preventive care policy when it needs that distinction recorded.

The S0612 and S0613 mix-up causes most billing errors here. The numbers sit next to each other, so billers assume S0613 is a scaled-down S0612. The two codes answer different questions. S0612 records that an established patient had a full annual gynecological exam. S0613 records that the visit covered the breast exam and stopped short of the pelvic evaluation.

Documentation decides the code, never the reverse. If the note records a pelvic evaluation and the claim goes out as S0613, the service is under-coded. If no pelvic evaluation took place and the claim goes out as S0610 or S0612, the practice has billed for work that did not happen.

There is no HCPCS code S0614

Coding cheat sheets and forum posts occasionally list an S0614 for a preventive gynecological examination. No such code exists. The official screenings and examinations range runs S0610, S0612, S0613, and then jumps to S0618 for audiometry in a hearing aid evaluation.

If a superbill or claim template in your practice still carries S0614, retire it before it produces a rejection.

Medicare and Medicaid coverage for S0613

S0613 is not payable by Medicare, and no annual update will change that. CMS assigns S-codes coverage code I, which places them outside Medicare payment altogether. A claim sent to Medicare fee-for-service comes back denied.

The CPT preventive medicine codes are no substitute. Traditional Medicare does not cover 99381 to 99397. Use G0101 for a cervical or vaginal cancer screening with pelvic and clinical breast examination. Q0091 covers obtaining and conveying a screening Pap smear.

The annual wellness visit codes G0438 and G0439 cover the broader preventive encounter. Laboratory work on a screening Pap smear bills separately, under screening cytopathology codes such as G0123 and G0141.

Medicare Advantage is the exception worth checking. Some Advantage plans follow commercial payer rules rather than traditional Medicare rules, and a few will accept S-codes. Confirm with the specific plan before you submit.

State Medicaid coverage for S0613 varies considerably. Some states list S-codes directly on their fee schedules. Others require CPT preventive codes instead and accept S-codes only as supplemental reporting.

Check your state Medicaid agency’s current fee schedule and billing manual before you assume S0613 is billable. For practices that also bill reproductive health codes, this payer-by-payer verification should already sit in your standard pre-claim workflow.

How to bill HCPCS code S0613: Medicaid and commercial payer guidelines

Accurate S0613 billing runs on documentation first and code selection second. The provider’s note has to confirm that a clinical breast examination took place and that a pelvic evaluation did not. Without both elements on the record, the claim is vulnerable to audit.

Billing staff can work through this five-step check on each S0613 claim. Structured pre-submission review is how a preventive claim goes out as a clean claim the first time.

1. Confirm documentation: The encounter note must state that a clinical breast exam was performed. It must also state that a pelvic exam was not performed or was deferred with a reason.
2. Verify payer coverage: Confirm that the patient’s primary plan accepts HCPCS S-codes. Medicare fee-for-service is an automatic no. Run eligibility verification before the visit for Medicaid and commercial plans.
3. Select the companion ICD-10 code: Pair S0613 with an appropriate Z-code diagnosis from the crosswalk below. A missing or mismatched diagnosis is a top denial trigger.
4. Apply any required modifier: If the visit also included a problem-oriented service, many payers want modifier 25 on the E/M code. Check plan-specific modifier rules.
5. Submit and track: Monitor claim status and log denials by reason code. A run of CO-4 or CO-97 denial codes points to a coding or documentation issue rather than a payer quirk.

ICD-10 codes to use with S0613

Every S0613 claim needs a supporting ICD-10-CM diagnosis code. Two mistakes drive avoidable denials here. One is submitting the procedure code alone. The other is pairing it with a diagnosis that does not match the service. The codes below are the pairings most often used for an annual gynecological examination without pelvic evaluation.

Pick the ICD-10-CM code that best reflects the clinical reason for the encounter. Z01.419 is the default for a routine annual exam with no findings. Z01.411 replaces it when the provider noted abnormalities during the breast exam.

For visits framed around breast cancer screening, Z12.39 or Z12.31 may better support medical necessity. Check every code against the CDC/NCHS ICD-10-CM web tool for your billing period, since diagnosis codes update each October.

S0613 fee schedule and reimbursement rates for 2026

No single national fee schedule sets the rate for HCPCS code S0613. Because Medicare does not pay the code, there is no CMS Physician Fee Schedule amount to reference. Each state Medicaid program sets its own rate, and commercial payers negotiate theirs through provider contracts.

Use these sources to find your current 2026 rates. The CMS Physician Fee Schedule lookup will confirm whether a related G-code or CPT code carries a Medicare rate. That helps when a Medicare Advantage plan crosswalks S-codes to CPT.

• State Medicaid: Download the current fee schedule from your state Medicaid agency. Rates vary widely, and some states do not list the S-code at all.
• Commercial payers: Check your provider contract or call the payer’s provider relations line. Some plans publish fee schedules in their provider portals.
• HCPCS lookup tools: The AAPC HCPCS code lookup confirms descriptors and categories, but it carries no payer-specific rates.

Never price a claim from a third-party estimate. Rates change mid-year, and a payer-specific coverage policy can override a published S-code fee schedule entirely.

Modifiers applicable to HCPCS code S0613

Modifier requirements for S0613 vary by payer, and no modifier applies universally. The table below covers the ones most often relevant to S0613 claims. Verify each plan’s modifier rules before you submit.

Modifier 25 is the one that comes up most often. Say a visit includes the annual preventive examination plus a separately documented problem-oriented service. An example is evaluation of a new breast symptom.

Modifier 25 on the E/M code then tells the payer that two distinct services took place. Without it, many payers bundle the E/M into the preventive code and pay once. Tracking modifier denial patterns in your practice management platform shows you which payers require it.

Documentation requirements for S0613

A payer reviewing an S0613 claim looks for two things in the note. The record has to show a clinical breast examination, and it has to show that no pelvic evaluation happened at that encounter.

The absence of the pelvic evaluation needs to be affirmative in the record. A note that simply omits it reads as an incomplete exam. State that the pelvic evaluation was not performed, and give the reason.

• Breast exam findings: Record the examination of both breasts and the axillae, with findings, in the physical exam section of the note.
• Pelvic evaluation status: State plainly that a pelvic evaluation was not performed, and why. Common reasons include patient declination, no clinical indication, or a separately scheduled exam.
• Preventive intent: Show that the encounter was an annual preventive visit rather than a problem-focused one.
• Diagnosis linkage: Record the diagnosis supporting the claim, usually Z01.419 or Z12.39, and match it to the code you submit.
• Patient status: Note whether the patient is new or established, so the record still supports S0610 or S0612 if a payer prefers those codes.
• Signature and retention: Keep the note signed, dated, and retrievable for the payer’s record retention period.

Hold the same standard on visits where a problem-oriented service ran alongside the preventive exam. The two services need separate documentation before modifier 25 will survive review. Practices working to HIPAA-compliant documentation standards should keep the breast exam in the provider’s physical exam section, where a reviewer expects to find it.

How Pabau keeps S0613 claims clean

Static code lookup databases tell you what S0613 means, and they stop there. Practice management software like Pabau earns its place after that. It submits the code, tracks denials by reason code, and shows you the patterns across your payer mix.

Pabau’s claims management software lets OB/GYN and pelvic health practices configure HCPCS Level II S-codes directly in their billing workflow. Billers build templates that attach Z01.419 or Z12.39 to S0613 by default, instead of looking up the pairing for every encounter.

They adjust when findings call for a different diagnosis. Fewer preventive care claims go out missing a diagnosis, so fewer come back denied.

Pabau also connects to a medical claims clearinghouse, so claims leave the same system that holds the clinical note. Our Claim.MD integration submits preventive care claims and returns payer responses without a separate billing portal. That shortens the loop between a denial and its fix.

The documentation layer sits in the same place. Digital intake forms capture the visit reason and consent before the appointment. The provider’s note then confirms that the breast exam was performed and the pelvic evaluation deferred.

That record links to the encounter and is available at submission. Audit responses get easier when every piece of encounter data lives in one system.

• Code templates: Pre-configure S0613 with its standard ICD-10 pairings, then adjust when findings change the diagnosis.
• Payer rules: Store payer-specific modifier requirements, so billing staff do not have to memorize which plans want modifier 25.
• Denial tracking: Monitor S0613 acceptance rates by payer, so your denial management catches a coverage policy change before it becomes a revenue problem.
• Audit readiness: Linked clinical documentation means provider notes are retrievable the moment a payer requests records.

Streamline preventive care billing with Pabau

Pabau supports HCPCS Level II S-code billing end to end. Configure preventive care codes, attach the right ICD-10 pairings, and submit clean claims without switching systems.

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Conclusion

S0613 billing goes wrong in two predictable places. The first is the payer mix, because Medicare denials are automatic while Medicaid and commercial coverage varies by state and plan. The second is code choice inside the family, where S0610 and S0612 turn on patient status and S0613 turns on what was examined.

Reading the family as a comprehensiveness ladder turns a clean preventive claim into a denial. So does reaching for a code that does not exist, like S0614. Set the payer rules and the documentation standard once, and both problems stop recurring.

Pabau’s claims management tools help preventive care practices configure S-code billing correctly, attach diagnosis codes by default, and track denial patterns by payer. To see how Pabau handles HCPCS Level II billing workflows, book a demo.

Continue your research

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