EM Coding Alert

Specialty Spotlight:

Find Out How to Code This Common Ob-Gyn Procedure

Published on Fri Sep 22, 2023

Remember: Don’t forget to consult CPT^®guidelines.

A patient returning for a repeat pap smear after abnormal or inconclusive results is a scenario common to ob-gyn practices and coders.

Choosing the appropriate evaluation and management (E/M) service code is crucial to reporting this situation correctly.

When a patient returns because the Pap smear results are determined to be abnormal or display insufficient cells, you know the ob-gyn is going to perform a repeat smear — but do you know how to report this? The truth is that you need to rely on precise E/M and diagnosis coding to receive the reimbursement you deserve.

Lean on a Visit Code

When the patient comes in for a second Pap smear, submit the appropriate E/M service. CPT® does not include a code for taking the Pap, so you should use the office visit code (99211-99215).

You will probably report 99212 for the Pap retest visit because the patient is here only for the Pap smear.

That translates to almost $57 per visit, using the Medicare Physician Fee Schedule national rate. Code 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) carries 1.68 relative value units (1.68 RVUs x 2023 conversion factor 38.8872 = $56.88).

Consider This Criteria for Collection

Private payer: Some private payers will reimburse for handling the repeat Pap smear specimen (99000, Handling and/or conveyance of specimen for transfer from the office to a laboratory), but under CPT® rules, you should not report this handling code unless the office incurs an expense over and above normal costs (such as, paying for someone to deliver the specimen or using office equipment to process the specimen before transportation).

Medicare: But Medicare carriers consider the collection and handling part of the E/M service when it is done for diagnostic purposes, and you should not code for it separately. That is, if the Pap is repeated due to an abnormality, the code Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) may no longer be billed to Medicare.

Look to These ICD-10 Codes

You should use R87.61- (Abnormal cytological findings in specimens from cervix uteri…) as the diagnosis code if the ob-gyn repeats the Pap smear due to abnormal results. This code requires a 6th character, experts say. If you don’t include the 6th character, this could be a reason for a denial.

Example: A 36-year-old woman with multiple sexual partners presents for an annual exam. She has not had a Pap smear in four years. The Pap results return ASC-US, and the physician asks her to come back in four months for a repeat Pap to follow any abnormal cell progress.

When the patient returns, you should code the appropriate office visit with R87.610 (Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)) because this is what the provider knows about the patient’s condition at the time of the repeated Pap.

Navigate Inadequate Sample Situation

On the other hand, if the patient requires a second Pap smear because the first sample was inadequate (that is, the lab did not have enough cells in the specimen to interpret the results), you should report R87.615 (Unsatisfactory cytologic smear of cervix).

For example, the ob-gyn misses the cervical opening when taking a Pap smear because the patient is obese. The Pap result indicates the absence of endocervical cells, and the physician likely would require another Pap. In this case, you would submit the second Pap screening with R87.615, assuming this is not a Medicare patient.

When this occurs with a Medicare patient, your diagnosis code changes to Z12.4 (Encounter for screening for malignant neoplasm of cervix) for a routine re-screening or Z77.9 (Other contact with and [suspected] exposures hazardous to health) if the patient was considered high risk. But remember, Medicare will require you to bill this repeat Pap using code Q0091 rather than an E/M service, because Medicare still considers this to be a screening.

And since you are repeating it, you should add modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional) to this Q code.