# PAP Smear documentation



## sbrown64 (Jul 9, 2009)

Situation:  Well woman encounter and the only documentation that a pap was performed is on the superbill. The exam in the encounter is a full Gyn exam (actually a comprehensive exam), but there is nothing that states a sample was taken for a PAP.

Can anyone direct me to a source which states the pap should be documented?

Thanks - Schawn


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## kbarron (Jul 9, 2009)

If it is not documented, it is not done. The note needs to specify that a pap was done.


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## vikas.maheshwari (Jul 10, 2009)

Ask your ob-gyn why she isn’t documenting seven of the 11 required elements to get paid? This suggests poor documentation. If your ob-gyn routinely does not document the required elements, then you cannot bill G0101 (Cervical or vaginal cancer screening; pelvic and clinical  breast examination). The patient will be responsible for the entire non-covered service. If this is a covered year, then the patient will be very unhappy.

You can bill Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the collection of the screening Pap.

That way, at least the patient would not have to pay for a small portion.


The 11 elements to choose from are breast, external genitalia, urethra, urethral meatus, bladder, vagina, cervix, uterus, adnexa, anus and perineum, and rectal exam.

If the patient has had a hysterectomy, the physician need only document that these three elements (uterus, cervix, adnexa) are surgically absent in addition to any other four elements to meet Medicare requirements.



Thanks

Vikas Maheshwari
MBA-HCS, CPC-H


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