Internal Medicine Coding Alert

Question: We received a Pap test order 13 months after the previous test due to “high-risk sexual behavior.” However, the ordering physician listed the diagnosis as Z12.4 (Encounter for screening for malignant neoplasm of cervix), which resulted in a denial. Is there anything we can do to get the payer to reimburse for this screening?

Minnesota Subscriber

Answer: The  denial  probably  came  because  the  ordering  diagnosis  gives  no  indication  that  the  patient  is  high  risk,  and  you  exceeded  the  two-year  frequency  limitation  for  screening  Pap  tests.  However,  Medicare  and  most  other  payers  will  cover  screening  Pap  tests  once  every  year  if  the  patient  is  considered  “high  risk,”  so  with  proper  documentation,  this  payer  should  cover  this  test.

You’ll need to ask the ordering physician to specify the high-risk sexual behavior that triggered ordering a screening Pap test earlier than Medicare and other payers typically cover. Then, you’ll need to resubmit the claim with the appropriate diagnosis codes.

Remember: Screening  means  that  the  physician  orders  the  test  in  the  absence  of  signs  or  symptoms  of  the  disease.  This  is  still  a  screening  test  if  the  patient  hasn’t  had  any  signs  or  symptoms,  such  as  an  abnormal  Pap.

The  conditions  that  Medicare  considers  valid  to  justify  higher-frequency  screening  Pap  tests  include  the  following,  some  of  which  relate  to  high-risk  sexual  activity:

• Early onset of sexual activity (under 16 years of age);
• Multiple sexual partners (five or more in a lifetime);
• History of sexually transmitted disease (including HIV infection);
• Fewer than three negative or any Pap smears within the previous seven years; and
• Diethylstilbestrol (DES) exposure of daughters of women who took DES during pregnancy.

Here are some of the diagnosis codes that ICD-10 provides to describe these conditions:

• Z72.51, High risk heterosexual behavior
• Z72.52, High risk homosexual behavior
• Z72.53, High risk bisexual behavior
• Z20.2, Contact with and [suspected] exposure to infections with a predominantly sexual mode of transmission
• Z86.19, Personal history of other infectious and parasitic diseases.

Bottom line: Ask the ordering physician to identify the high-risk  sexual  behavior  factor,  and  assign  one  of  the  preceding codes or other appropriate code along with the screening Pap test ICD-10 code Z12.4 (Encounter for screening for malignant neoplasm of cervix). Select the appropriate procedure code that your payer accepts to describe the Pap test method your lab performs, such as G0123 (Screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision) for Medicare, or 88142 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision) for other payers that don’t recognize the HCPCS Level II Pap codes.

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