Ob-Gyn Coding Alert

Presented by Melanie Witt, PN, CPC, MA

The following supplement to Radiology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you-re not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Melanie Witt, RN, CPC, MA, is an independent coding education consultant and was active in ACOG for many years. She is a well-known speaker and recognized expert in the area of coding and reimbursement for ob-gyn services. In addition, Ms. Witt is the consulting editor for Ob-Gyn Coding Alert.

Thank you.  I welcome you all to the audio-conference this morning.  Today, we are going to talk about Pap smears and I plan on discussing this subject in great deal of detail, but before we get started I thought maybe I would give you a quick overview of what we are going to go over today, so that you will hopefully know whether or not some of your questions will be answered during the presentation.  Because I think that history is important, I want to start with the history behind the Pap test and then move onto some information about cervical anatomy and the effectiveness of the Pap smear.  I think that those are important things for the coders to know as well in addition to just how to code for them and also on a personal note because most of us listening today are women, I think it is important that we understand the importance of this particular screening test as it is life saving.  Then, I will be describing the basic procedure and some other related techniques that go along with this and then we will go over some of the recommendations for the frequency of the test and briefly look at that difference between the screening and the diagnostic test. In the last half of the presentation, I plan on going over diagnostic coding, which is very important for all of us to get these things paid, and then go onto to look into how a lab actually bills for Pap smear.  Now some of you who are strictly office, you can go to sleep during this portion of the talk if you like and then perk up at the end when we finally wind up for the important point for all of us: how can a physician bill for a Pap smear both under normal circumstances and a few unusual ones that I have picked up over time, some questions that I have got.  So, let us get started.

The Pap smear is actually named after Dr. George Papanicolaou and because he has such a long name, it basically got shortened to Dr. Pap, so everyone knows him by that name.  He came from Greece and he immigrated to the US and finally he died in 1962.  He had a very interesting career.  He actually went on and got a Ph.D. in zoology in addition to being a regular physician and then he came to US and did some research.  When he was at Cornell University, he studied the role of chromosomes in sex determination and when he was doing that, he noticed that there were recurring changes in the cells in the vaginal discharge of a guinea pig over the life of the menstrual cycle.  When he extended this study to humans, he began examining vaginal smear changes and he unexpectedly discovered that women with uterine cancer had abnormal cells that were large and deformed.  And so he came up with this test that he could do on women to detect the presence of these abnormal cells way before cancer was developing in the body, which was really kind of neat.  But it was not until 1941 that he and another gynecologist, the guy's name was Dr. Traut, actually published a report and it was entitled, -Diagnosis Of Uterine Cancer By Vaginal Smear.-  And basically the report demonstrated how cellular abnormalities could be detected before the tumor became invasive.  It was really a revolution in the management of cervical cancer and so the Pap test was very soon accepted as a routine screening technique and the use of this test improved the health of women dramatically.  Probably within just 20 years of it coming to fruition.  And cervical cancer went from being the number one cause of death due to cancer in women to third place, and this is quite something for something that appears to be as innocuous as that would be.  This is a little sidebar.  It is also interesting, for me anyway, that colposcopy was invented back in 1925, but it took over 30 years to get to this country to be accepted as a diagnostic tool.

Some of the techniques that I am going to be going over, some of the newer techniques that are being developed to detect cervical cancer, it may, in fact, be a while before some of them are accepted into the mainstream.  So right now what we have to fall back on is the Pap test, so what is it exactly?  Well, it is a Pap smear.  It could be called a Pap test or the Pap or whatever, but basically it is a procedure where a sample of cells from a woman's cervix are collected and spread on a glass slide.  This has always been the conventional Pap smear technique.  The cells are stained and then are examined under a microscope and what you are looking for is premalignant or malignant changes in those cells.  The exam is reported by a laboratory that is qualified under the Federally Mandated Clinical Laboratory Improvement Amendments, or CLIA as we all know it for short and they are the ones who interpret the test.  So when we get to the portion when we talk about how a lab bills, the lab of course is going to be billing laboratory codes for their interpretation.  The physician of course would never bill the laboratory codes for any purposes because they are not qualified to do this high-complexity test in most offices anyway.

So how good is this Pap test?  Unfortunately, there are going to be a few women who are going to develop cervical cancer despite having regular Pap screening--that we know already.  And basically the reason for this is because of two things.  When anytime you are talking about the Pap test, you are talking about two items that measure its ability to detect cancer and the first one is called sensitivity of the test.  This means the ability of the test to detect every single abnormality.  Then, the second item is called specificity of the test and this is the ability of the test to avoid classifying a normal smear as abnormal.  So while both of these test requirements are extremely good for the Pap test, they are not perfect.  You should be aware though that a Pap test does not detect cancer of the ovary, it does not detect cancer of the vagina, it does not detect cancer of the uterus, it is specifically for cancer of the cervix.  In previous studies, they discovered, however, that if you could detect cancer of the cervix first, it would almost ensure that you could catch uterine cancer at the same time because the cells might migrate up the endocervical canal and gravitate into the body of the uterus, so it is good for that reason.  But in spite of all the best collection, specimen handling, and screening procedures out there, there is still going to be a false negative or a missed lesion rate of about 4%, and unfortunately up to 2/3 of these false negative Pap smears result from factors that are more related to the collection procedure.  But the good news is that we have natural history on our side because cervical dysplasia and carcinoma take a long time in terms of years to develop into invasive cancer, so if a woman has a yearly Pap test being performed, then the chances of a lesion being missed are very, very low. 

The specificity that I talked about in the Pap test is mainly a concern, however, when the test comes back showing atypical squamous cells of undetermined significance and that is basically what we refer to as an ASCUS slide.  This result actually occurs about 25% of the time, but in the majority of the ASCUS cases, the cervix is actually normal, but there are a number of patients with an ASCUS Pap smear who have also significant disease.  So the problem has always been how do we identify the high-risk patients reliably?  And we will talk about that pretty quick.

So how is a Pap smear done?  There are some different ways of doing it, but I would wager that the majority of you listening in here today have had a Pap smear done, but that you have been in a passive role, in other words you are the patient and you are not seeing what the doctor is actually doing, so I will give you an idea of what goes on when this Pap smear has been done.  The Pap smear that is being sent to the laboratory for the interpretation is normally collected at the time of an annual well-woman visit and it really is in our goal to do the screening pelvic examination because it is done at the same time.  This is because the physician will usually combine an exam of the genital system with the collection procedure.
 
In some cases, the Pap test is performed for diagnostic reasons and for other times it is done for screening, but the technique used in each instance will be the same.  You can perform the collection and exam in any setting, of course, it can be done in the office in the outpatient clinic or in a hospital and specimen can be collected either by the physician or by another specially trained healthcare professional or physician's assistant or nurse practitioner or certified nurse midwife, it would not normally be done by an RN or an LPN, etc.  Most of us know the routine, you know, you are positioned on your back with your feet in stirrups, so that the physician can start the exam, and normally he is going to take a look at the external genitalia.  He will probably look at the rectal area, he will look at the urethra and then he will slide a speculum into the vaginal canal and hopefully it has been warmed beforehand.  If there is some mucus present, he is going to use a cotton swab to get rid of it.  Then, once he has the cervix in sight, he is going to take a small cervical brush or spatula and he is going to insert it into the opening of cervix.  This is referred to as the cervical os.  He is going to twirl it around and then collect a sample of cells.  And the first sample is going to be taken from the area that we call the transformation zone because this is the place in the cervix where the majority of cancers are found.  Because the sample is coming from the inside of the cervical canal, it is also sometimes referred to as the endocervical sample.  Then, a second sample is going to be collected from the area surrounding but not entering that cervical os and that area is called the exocervix or the exocervical sample.  It generally takes less than 2 minutes to collect both samples, so it is not a hard procedure to do by any means.  Usually most women will feel nothing or feel a little small pinch during the process.

There is a little history that also goes with the collection device as well.  For a lot of years, they used to use a wooden spatula.  About 15 years ago, they discovered that they could actually improve the collection technique if they could get an instrument to get more cells in the sample and that actually would increase the sensitivity without increasing false positives.  So, they used to use saline-dipped cotton swab and then later they used endocervical brush, but currently there is a combination of a spatula and a brush that is really considered the most effective way to collect these specimens and it has been approved to collect these cells from both the exo and the endocervix at the same time, so even the collection device has had some changes to it. 

But then, okay, we have collected the sample and now what happens is, it is gently smeared on a glass slide and some kind of fixative is sprayed on top of the specimen and that prepares the cells on the slide, so they can be transported to the lab.  Now, some physicians are going to place both samples on the same slide, others may prefer to use separate slides, it really is a matter of preference and it does not affect the analysis for the lab.  Then, the specimen will be labeled and it will be sent to the lab who will be doing the interpretation. 

Normally, the lab is going to pick up the specimen at the office, but in some cases, the office may have to deliver the specimen to the lab.  And the reason I am bringing this up at all is because for those payers who say, -sorry, we don't pay for handling of the Pap smear specimen,- you might be able to make the case for being reimbursed for that if you can show them that you had office expenses in the process of doing this.  But for offices that receive the equipment and the testing supplies from the laboratory and then simply spray on a fixative and march it to a box in the back room, they may be less likely to want to reimburse you for that particular service. 

They have taken a Pap smear specimen and to wind things up, the doctor will then perform a bimanual exam and that will be in addition to the Pap smear.  And that part of the exam is where the physician is feeling for the ovaries and the uterus with a hand on top of the abdomen and then two fingers inserted into the vaginal canal.  And they may or may not do a rectal sample as well and the reason for the rectal sample, of course, would be to do a Hemoccult smear to test for occult blood.  So, as you can see, if all of these steps are being followed and a pelvic exam has been performed at the same time the specimen collection, which is why most people say it is a pelvic Pap.  It is because she is there and it is open and this is what we do.

Now, there is also a different kind.  That was the conventional way of doing it.  There is also a different kind of Pap smear and a lot of you probably recognize the term of thin prep.  This test actually differs from the standard Pap smear, but only in one way and that is how the specimen is preserved and then later prepared by the lab.  The collection procedure is done the same way, but the physician might in fact use one of those newer collections to take the sample of the endo and exocervix at the same time.  And then after the sample is collected, it is put into a vial that has a special transportation medium that is called Preservcyt or something like that.  Then, that is kind of agitated in the liquid for a prescribed period of time and in the vial of fuels.  It is labeled and then it is forwarded to the lab.  The bonus is that the sample can remain in the liquid for up to three weeks and still be interpreted and then at the lab, the sample and the liquid is converted to a thin prep, which transfers the sample to the slide.  To do that, the cells in the sample are dispersed or randomized and then collected onto something called a membrane filter and what they do is they draw the sample across that filter with a vacuum until they get an optimal number of cells and then these cells are transferred to a glass slide by placing that filter onto the slide and using some positive pressure to complete the transfer.  So you would end up with a thin prep which is a single layer of cervical cells and they are free of things like debris and stuff like that. 

What is interesting is that somebody had described it as a cereal bowl with raisins, if the raisins were clumped together and you stuck a spoon in the bowl, you might or might not come up with raisins.  If you dispersed them evenly, your chance of coming up with raisins in a spoonful is more likely.  This is what the liquid-based technique does truly and so it is like a sub-sampling.  So I thought that it was an interesting analogy that I would share with you.  So, the thin prep is actually marketed as being better in detecting better than a conventional Pap test in detecting both low grade and high-grade squamous intraepithelial lesions, so that is the advantage to it, so thin prep is its trade name.

Another kind of liquid-based system out there now is a SurePath and it originally was thought not to be as effective as thin prep, but there have been some improvements made to it over time, so actually it has in fact been moved up to the same category as a thin prep with all of the changes that have been made to the product.  So basically a liquid-based system is good.  The other advantage of course to a liquid-based system is that you can use it to do HPV testing if that is found to be necessary with the same sample; you do not have to resample the patient.  So that is an interesting sidelight to that.

Then, there is something called PapSure.  Now, the PapSure currently does not have a CPT code.  To bill for that, you would have to go to the Category III codes in the back of the book, the 0031T which includes normal Pap sampling and then the 0032T and that is for directed sampling of abnormal tissue.  But you are basically washing the cervix with a mild vinegar and then you are examining the Pap smear under a blue light.  It is still not in work for a new code by next year, so it is still going to be considered investigational.  Some physicians really that I have talked to think that this may not be all that is cut out to be, but if you have abnormalities, it might be okay.

The other one is called Papnet and actually in the slide I have indicated that it is automated re-screening and that it may be less expensive technique and is less labor intensive.  But actually the Papnet system is really used to detect abnormal cells that were missed on a standard Pap smear.  This system performs a recheck of a negative Pap result, using a video screen that detects and magnifies abnormal cells that were ostensibly missed by the technician's eye.  Some of the studies I have read say that, while this concept is sound in principal, there really is no automated re-screening technology to date, basically, that can improve much on the poor sensitivity and specificity of the Pap smear that goes along with the regular manual screening that is done by a technician.  It is kind of one of those things that if you invent something, you are hoping someone will come and use it, whether or not this is going to be a good idea in the future or not.  But I foresee that if there is an increase in the number of Pap smears being done that a significant portion of those Pap smear samples is probably going to be interpreted with some form of automation.  It is for that reason that the Bethesda Terminology Committee has recommended that whenever a slide is prepared or interpreted using any form of automation, that fact should be mentioned in the report that is returned to the doctor just to give them more information.

Now that we have got these little nuts and bolts out of the way, we can talk about the Pap smear frequency guidelines, etc.  I wanted let you know in particular because your current slide is no longer correct.  ACOG has come out with new guidelines for Pap smear recommendation and they are the same guidelines now that have been accepted by the American Academy of Family Practitioners and the American College of Surgeons and also the Cancer Institute, so they are all marching in stepping order now on these guidelines.  So, you want to make a change and take some notes here.  The recommendations are now as follows: they believe, you can do or should do a Pap smear annually beginning within three years of sexual activity or by the age of 21 up until the age of 30 and they have stated that both the liquid-based systems and the conventional Pap cytology are acceptable for screening, either one.  Now they said you could change and do a Pap smear every 2-3 years after the age of 30, but only if there is no history of CIN-II or CIN-III that is the carcinoma in situ or the dysplasia, the mild and moderate dysplasia codes, where the patient had no DES exposure when she was in her mother's tummy and she has had no exposure of course to HIV.  So, it is a very narrow band there.  They have also stated that physicians can consider discontinuing testing in women who have had a hysterectomy for a benign disease and who have also had no history again of CIN-II for the moderate or mild dysplasia or have had any form of genital cancer.  If the patient had a history of this and this is going on, they have recommended that you screen annually until you get three negative results that have been obtained and then you can decide what to do after that.  So this actually at some point may impact what Medicare decides to do, because if a women is over the age of 65 and has always had negative Pap smears and has never had a history of anything wrong and is not in a high-risk group, ACOG is actually saying, you probably do not have to do these but every 3-4 years or maybe not at all.  So, it is interesting to see how the rules go and what might happen with it later.  But so far, Medicare is not jumping on that band and so you just have to wait and see how this plays out.

So what makes a woman high risk for cervical or vaginal cancer?  I have listed some of the reasons in your handout and you may even notice that they are practically the same as the criteria that are used by Medicare and of course that is not a coincidence either.  But things like onset of sex at an early age, multiple sexual partners, history of sexually transmitted diseases, exposure to DES, and previous abnormal Pap results.  It is interesting, I have been speaking with a few physicians over it lately and they have said basically that they think that maybe less than 10% of women in the US currently who are of sexual age or having sex could actually be considered in the low-risk category anymore because of the prevalence of high-risk sexual behavior.  It is kind of scary I think.  But anyway many women might even be surprised to learn that smoking puts them at risk for developing cervical or vaginal cancer as well, but Medicare of course does not have that on their list of criteria. 

There are other recommendations as well for different circumstances, for instance if the woman is 65 or older, the recommendation is that you can, as I said before, actually discontinue the testing if she has had three normal Paps in a row and is at low risk for developing cervical cancer.  I think probably though that most physicians would not want to discontinue testing, but they might reduce the frequency.  And also another recommendation is that you can discontinue vaginal screening in women who have lost their uterus or their cervix for nonmalignant reasons and the patient is not otherwise at high risk.  So we just have to wait and see how this plays out with Medicare, but hopefully it will be fine. 

Moving right along, we turn to the Medicare guidelines.  Now these do not quite match the recommendation from the other organizations because they are now allowing you to screen once every two years if the patient is low risk and ACOG is saying you could go 2-3 years.  So, it is within the range.  Then, screening every year for a woman who is at high risk is in their category of their rules.  The problem is, it has to be by their rules and not necessarily the previous list we discussed of how a woman can be in the high-risk category.  The Medicare program does not consider a vaginal Pap that is taken because the patient had uterine or cervical cancer to be a screening Pap smear.  You need to make note of that because in this case, it is going to be a diagnostic Pap smear and it has different billing implications for you guys and we will discuss that later on and how that changes the scenario.

We were talking about Pap smear guidelines and everything, but we cannot discuss that without also in the same breath talking about HPV testing.  Here is the big dilemma with this HPV thing.  It is almost virtually impossible for a woman to develop significant squamous lesions without first having had an HPV infection, but most women who have had an HPV infection never develop significant intraepithelial neoplasia, in other words cancer.  So the question is, is this something that you should be doing routinely or is this something that you should not be doing routinely?  And of course there are different kinds of viruses.  There is a low-risk type, HPV type 6 and 11 are considered low risk and they are the ones that are basically associated with genital warts.  Then, there is this long litany of numbers that are high risk for HPV and these are the types of HPV that are more associated with the development of dysplasia and cancer.  So, it would be important to do this testing.  Well, for the testing again, as I have said earlier, if you have done a conventional Pap smear collection, you cannot do the HPV testing automatically, you actually have to go and get another sample to do it.  But if the patient was having the liquid-based or the thin prep, then it could automatically be done.

The recommendation is that you would do HPV testing if you had a Pap result that was ASCUS or low-grade squamous result on the initial Pap smear and you would do it on women over 30 as well.  And the reason for that is, in the recommendations they discovered, that if you test a woman for HPV automatically when she is under 30, it is almost always going to come back positive.  What you want to do is find it after the age of 30 because that is the kind that leads to the cancer.  So that was the recommendation: do the combined testing after the age of 30, unless of course she has had a previous test showing she had HPV.  But what is interesting is that if both the Pap smear and the HPV test which were done are both negative, the woman at that time should not be re-screened more frequently than every three years and that is the absolute newest information we have on that.  This is the recommendation from ACOG, from the National Cancer Institute and from the US Task Force on Prevention, and the American Society of Colposcopy and Cervical Pathology.  They all are in marching step order, so if it is a negative HPV and Pap test, the woman can then be re-screened every three years, but no sooner than that, it is not necessary, so that might change some things too.

Now we are going to talk about the difference between screening Pap Smears and diagnostic Pap smears.  Screening Pap smear means all the patients are screened under some general frequency guidelines.  In other words, she has no current problems, she has got no past history of abnormal Pap results or cervical disease and she tends to have a screening Pap smear whether she is in a low risk or high-risk category for developing cancer.  But the problem with the screening is that we are looking for a potential problem that is not currently evident and that is why it is a screening.  But a diagnostic Pap smear is different.  This is a patient who is being treated or has been treated for cancer of the cervix, cancer of the uterus or cancer of the vagina.  She has had a previous abnormal Pap smear, she presents with signs or symptoms that the physician thinks are related to a GYN disorder, or she has had abnormalities of vagina, cervix, uterus, ovaries or adnexa found during an exam.  You will notice, however, that on this list nowhere is it listed -history of breast cancer.-  So history of breast cancer is not a criteria for yearly Pap smear screening test.  If the physician is that worried about the breast cancer retuning and wants to make sure it has not metastasized, then he could put it in the category of a diagnostic Pap smear, but it is not considered a screening at that point.

Then, this brings us to diagnostic options.  If we are dealing first with a private payer and dealing with a screening, we are going to start with the cervical Pap smear itself, and the specimen collection at the time of annual exam is coded diagnostically using V72.31.  That just says, annual exam with or without Pap smear, but if you are doing a Pap smear, this is the code we would use.  If the purpose of the visit is only for the collection of a Pap smear specimen, then you would use the code V76.2.  And if the purpose of the exam was to do a repeat Pap because on the first Pap, the lab came back and said there were insufficient cells on the first specimen--and this is private payer only, not Medicare--it would be 795.08 that would be the code we would use, so insufficient cells or insufficient sample, for any of those wordings, this is the code that you can use when you bring her back to do another Pap smear. 

If you are going to do a vaginal Pap smear, the specimen collection at time of the annual exam, you are going to start with that V72.31 and then ICD-9 leads you to two additional codes, the V76.47 that would be your Pap screening, actually vaginal screening, so you have had the uterus out for nonmalignant reasons, and then V45.77 which is an additional code that says guess what, the uterus is missing.  It seems like a little overkill to me but those are the directions.  If you are only going to do a specimen collection again, this time it is V76.47 plus V45.77 and that is how that is going to work.

If it is Medicare, however, we have a different set of codes.  Now, originally when you did the Pap smear, they said -we can only do it for V76.2---that was in the old days.  Then a couple of years ago, they added the code V76.47 and V76.49 if the patient did not have her uterus in any longer and it was removed for nonmalignant reasons.  Well, there is another new change, we know how we like change, starting July 01, 2005.  They will accept the code V72.31--hurray, we all get to be on the same page here!  But only if the full GYN exam is also performed.  So if you are only billing for the Pap smear collection and you are not billing for the pelvic exam at that visit, then you would not use V72.31.  So they made sure that you knew that.

So for screening in the high-risk patient, Medicare says you are going to use the code V15.89 and then you are going to pick a code as a secondary code, it is not always required by every carrier out there, but some of them like to see it.  But basically what you are doing is, you are giving them the second code to tell them why she is in this high-risk category.  So for 5 or more sexual partners, it is V69.2.  If she had a history of sexually transmitted diseases, it would be V13.8, but those codes would go secondary, the first code on the claim form must be V15.89 in order for you to get this paid. 

Now, Medicare also has a secondary definition here; if the woman who was Medicare eligible was also of childbearing age, they will extend this to mean that she can be premenopausal, but the physician says she could still get pregnant based on her history and her findings.  When that scenario comes into play and this could happen for say a Medicare patient who was disabled, this would be one of instances you would think about.  Then, what they have done is said, we can do that cervical or vaginal Pap yearly or you can fall back on the other additional guidelines of the presence of cervical and vaginal cancer or other GU abnormalities during the preceding three years.  So if she had it four years ago, it does not put her in the high-risk category.  It has to have been within the last years and as I said before breast cancer does not count, so that is where you start.  But if you are going to do this on a Medicare patient and you want to put her in the high-risk category, she has to fall into one or two of those groups.

Now, for diagnostic Pap smear, the coding looks a little bit different.  For instance, if it is a vaginal Pap following the removal of cervix and uterus for cancer, then your primary code is going to be V67.01 plus you are going to add the codes that say, -by the way her uterus was removed,- and then you are going to add the code that says, -by the way she has a history of cancer.-  If it is a cervical smear that is a follow-up because of a previous history of an abnormal result, you have basically two code choices now, you have V13.29 which means, it could have been two years ago that she had this abnormal result and for some reason your doctor believes she should be having another diagnostic because he saw something, I don't know.  Or the V72.32, which basically means that she has had a previous abnormal Pap and now you have gotten the result and the second one is now normal and now you are following up on an additional Pap smear to let them know that that one is being done basically for diagnostic purposes still until you generally have three negative Pap results.  I just want to let you know that there is no time limit on the V72.32 code, so you could use that for the three consecutive follow-up Paps that all turned out to be negative, for instance.  Most physicians, however, after they have gotten that third one and it is still negative, are going to revert to -history of code- when they are doing this.  Or in some cases they may say -okay, three negative Paps, everything looks great, now we will revert you back to normal screening.-  That is also how you could do that.  So that is how that particular code is going to work for you in your favor, al least we hope so.  That code, however, V72.32 is not used for the Medicare program.

Now, when we are going to start reporting the diagnostic codes for the abnormal Pap results, some of you may have noticed over time that you have Pap results and sometimes you will see a path report that says CIN-I, CIN-II and then it will say ASCUS, etc.  The basic difference here is that the abnormal Pap smear results are almost always reported or should always only be reported on a Pap smear specimen.  When you get the CIN-I and CIN-II types of diagnoses coming in on your report, it means it really has been a cervical biopsy, not just a Pap with the cells, that you have actually taken a portion of the cervix and sent it in.  So it is just a difference, they practically mean the same thing, like the low-grade lesions are pretty equivalent to CIN-II and III and the high-grade lesions might be equivalent to CIN-III, for instance.  But the difference will be in the specimen that was used and how you report it, so for Pap smear you are going to be using abnormal Pap results if that is what you got.  And from low to high, basically it is going to be the ASCUS, which is the least worrisome of it all, and you are going to move up the line for your codes to the different types that you have. 

You also now have two new codes for HPV, the high risk and the low risk and again I have explained to you that there are high risk and low risk types of HPV and so the lab report that you get back will assign her the category that she is in.  But if you are going to bill 795.09, which is the low-risk HPV DNA test positive and I believe it is test type 6 and 11, you are also going to have to add another code for HPV, the 079.4 because the code category actually says other abnormal Pap smear and you need to specify what that other meant, but if you are going to use 795.05, you do not need the additional code to say it is HPV because by definition in the code it says HPV.  So that is how that is going to work.

If you got a glandular cell result, it is 795.00 and that is any atypical endocervical, endometrial or glandular cells and that would be the result that you would put on your claim form.  Then, in addition, of course, we have as I said a diagnosis for dysplasia, a diagnosis for cancer in situ and CIN-III, CIN-II and CIN-I and really the difference here is, as I said, is that the result is being reported based on a biopsy, not on Pap smear specimen.  Although some physicians look and say, -I don't need the lab to tell me what it is, I know what it is,- but truly you should be going by the lab results.  And if it is a Pap smear, you are going to get the Bethesda Terminology and the 795 codes.  Additionally, as I said, you can have findings of HPV, you might have condyloma in there that are being looked at, genital warts, you might find a result that comes back and says it is cervical Trichomonas or genital herpes, all of these things are also codable at the same time.  But at that point it is not so much of cervical cytology as that they have another condition going on.

So, that brings us to the laboratory part and this is the Pap smear interpretation.  We start with a request for the Pap smear of course and there is a list that I have given you on your slides that tells you the information that most of the labs want to see.  There are codes for laboratory screening tests that would be used for Medicare screening tests, the G codes and the P codes that labs would use and of course, not you guys in an office.  Then, there are liquid-based Pap test codes and there are other Pap smear codes, whether or not it is screening or re-screening.  Then, there are codes for the conventional Pap tests and there is a selection of all those again.  Whether it was the lab tech who did it, whether it was pathologist who was required for the interpretation.  Oh, by the way, 88141--pathologist interpretation means pathologist, this is not a code that would ever be reported by the physician who collected the specimen.  He is not interpreting anything.  He is collecting it and later on he is reading the report and reviewing it with the patient, but he is not interpreting it.  So 88141 is never billed by the physician, just the laboratory pathologist who is required because they have had an extra abnormal finding or something that they had to look at.  Again, there is another set of codes for liquid-based Pap test and another series of codes for an automated Pap test. 

This brings us to the billing part, the part you all have been waiting for.  So for screening, we all know Medicare has their rules.  There is one code for the collection of the Pap smear specimen and that is Q0091.  It is a carve-out situation.  That means they consider it a separately billable item, but it is a carve-out because it is part and parcel of the exam that is being done and so if they do not cover it, it would get thrown back into the preventive code that you will be billing the patient for, for the rest of it.  You can also bill that Q code with an unrelated and significant E/M service for a problem.  To do that, you would use the 25 modifier for that.  And again, the linking diagnosis for the low-risk Pap, we have given you all the codes in the diagnostic section and if a GYN exam was in fact done at the same time, you will fall back on V72.31 and high risk is going to be V15.89.

Now, that carve-out, I have given you an example on your slide on how that carve-out is supposed to work.  If you want to know where the carve-out rule is, you would go to the Claims Processing Manual and you would look in Chapter 12, section 30.6.2 and then you are going to reference the Medicare policy for carve-out rule.  In the old manual that used to part 3, Chapter 15, now they have renumbered everything.  So I have given you where the new section is and you can find this and you can go online to the CMS Web site and find this particular thing and download the information, so you will understand about the carve-out.  You also know that with Medicare you want to add a QA modifier, this is to get the waiver signed by the patient that if Medicare denies this for any reason, the patient is then responsible for that portion of the bill.

Medicare rules for the diagnostic, it is basically what they said is the doctor is not to bill for collection of a diagnostic Pap smear that is included as a part of E/M that is already being billed and of course they are not going to pay you for a handling fee.  Other payers have different rules.  Now according to ACOG, and I now we discussed this in other forms in different ways, but ACOG believes that the collection of the specimen is an integral part of that exam and not be coded out separately.  That said, ACOG has also indicated however that trying to get reimbursed for a handling fee for the time, work, and effort of labeling and then getting it to the lab box could appropriately be billed and that would be 99000.  Other private payers, I am told, are beginning to accept Q0091.  Some are not paying very much on that code, some are paying the Medicare label, I found out, but in that case they are paying less for the actual exam, so there may be a trade off here.  And at least in one instance, I have been told that the Q code is now the substitute for the annual well women exam and they pay $20.  So it is all over the place on how that is going to be interpreted.  Again, it is never appropriate, I can-t  say it often enough, but it is never appropriate to bill that laboratory codes for the collection of the specimen and do not use 88141.

Modifier-90 can be used if you are billing on behalf of the lab and they are not going to be submitting the bill, but again because of CLIA regulations, Medicare will not allow you to do that anyway, but other payers may still allow you to do that part of it.

Now we will come to the last part, which is the unusual coding situations and these are things that I have come across over the last year pretty much.  So we have got different scenarios.  First of all, the patient comes in for her annual exam, but is bleeding so the Pap smear specimen cannot be collected.  So that would be the first scenario.  Then  in the second scenario that the patient requests that only a Pap smear be done and in the third scenario the patient comes in for a repeat Pap smear after an initial Pap smear was abnormal and the last Pap smear was normal.  So what have we got here?  For the first situation, you are going to code for the preventive exam today.  This is one of your options and then you can schedule a no charge visit for the next week to collect the specimen if you want.  Another option could be you could code the preventive exam today with a modifier 52--and I know some of you are saying, but we do not use the 52 on an E/M code.  You cannot use the 52 on a regular E/M code, but you could potentially use it on a preventive code because there is no other code that you can downcode to in order to do this.  And then schedule a visit for the next week to collect the specimen and then charge a 99212 or may be a 99213 depending on what the documentation would look like for that.  The main thing is that the 52 modifier protects your fee profile so that you do not look like you have preventive services up and down the scale, you are charging one fee.  Or, you could reschedule the annual exam.  If you are going to do something like that, you need to let your patients know ahead of time that that is what you are going to do and how you would handle it if for some reason they could not do the Pap smear test at the time of that visit.

Okay! For the second scenario you would probably want to bill the E/M service code that matches the documentation, of course.  It will probably include a brief history, a pelvic exam and a straightforward medical decision making in most cases.  So again, it might be a 99212 or it might be 99213.  Your other option would have been to bill a preventive service with a modifier 52.  You could bill Q0091 if it was a Medicare patient or if the private payer accepts this code and of course, the diagnosis in this case would be V76.2.

In scenario three, I have listed them in order so that you can see.  The first visit, the first Pap smear is screening, so you use the screen diagnosis.  In the second time, you get those results and they are abnormal, so the patient comes back for a repeat, so now you are going to assign 795.01.  Now the reason I use that code is because if the patient comes back with anything other than ASCUS result, the colposcopy is going to be done, not a Pap smear that next visit.  You are actually going to do colposcopy with biopsy.  So that is why I use that as a preference.

Then on visit three, after visit two, she comes back and you get the lab report in and the Pap smear is normal and that happens a lot with ASCUS results--they do come back after the next one and they are normal.  They have just revert for some reason.  So it will come back normal so at that visit, the patient is coming back for a repeat after an abnormal and then we know we have a normal result now V72.32 and then for visit four, she comes back and there is another normal and you are still going to use the V72.32 again.

As we discussed a little bit earlier the repeat Pap smear for insufficient cells can happen for a lot of reasons, that is not because the doctor did a bad job.  It could be that there just were not any cells there to do, the older a woman gets, the less cells are going to be present, so it is a common result for an older woman anyway, and there could be a lot of reasons for it, but she might come back for that.  So you get to bill using 795.08 and you could just bill the regular 99212 or 99213 code.  If she was coming back, some offices are not charging.  They are saying, -well it was insufficient cells, we just hate to have her pay twice for the same thing,- and they are actually electing not to charge--that is your option.  If it is a Medicare patient, you get to bill it again using the Q0091 code, but you must add a 76 modifier.  If there is no 76 modifier, you do not get paid, and then you link it to the usual V76 code that they allow.  And then the final example that I thought was interesting, someone asked it a while ago, was how about a mentally retarded patient who is brought into the office for a routine exam and you do a complete history and the caregiver is there and she counseled and all of this kind of stuff, but the physician cannot perform the Pap smear because the patient is uncooperative.  So you use a little mild sedation before coming to the office and then the Pap smear was collected and in this case, it was collected in the hospital or it could be collected in the hospital under general anesthesia or could be conscious sedation for that matter.

So what are your options here?  Well, you are going to do a problem E/M service in this case with a modifier 25 to signify a decision to do a minor procedure.  The level of the code is going to depend on what you documented of course.  You can also bill the preventive service with the modifier 52 if they are going to accept that, and you are going to bill the exam under anesthesia code 57410, but again you need to check with your payers to see if they will actually accept that as a reason.  I have discovered in the last six months that a lot of Medicaid programs will not reimburse separately for an exam under anesthesia, even for a patient who is mentally retarded, to do the exam, they just simply would not reimburse it, they just say well too bad, so sad.  And then of course you do have your diagnostic options listed on the slides.

So that is the end of the regular material and I think we have about, I would say, at least seven more minutes that we could do some questions in.  So operator, I will hand it back over to you for the question part.

Thank you Ms. Witt.  Ladies and Gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press *1 key on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue, please press #.  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question, you may reenter the queue by pressing the *1 key.

Q & A Session:

Question:  Hi!  I have just a sort of general coding question, I have struggled and struggled finding a code for maternal DES exposure, what do you suggest using for that?

Answer:  It is actually in your ICD-9 book, it is in the perinatal chapter and if you go to the back to your ICD-9 book and it is actually listed under DES.  You can find it and it is in the perinatal chapter and the reason it is there and the reason you get to use that code on the women's chart is, she was exposed to this condition when she was in utero with her mother, so it does not matter if she is 50 years old, you still get to use that code.

Okay then let me add one last little thing, this question actually came in a couple of days ago and I thought it was interesting enough to add and so I will read this one. 

The patient is scheduled for a well women visit, no routine coverage on her Blue Cross policy, we collect for a visit and bill the patient for the lab charge, the Pap smear was done at that visit and it comes back ASCUS with negative HPV.  The patient gets a $350 bill for the lab.  The question is, since it is done on the well women visit is it legal to change the code for the lab charge since it came back abnormal to 795.01.  Okay coders! I am hoping that you are all saying no it is not legal, you may not do that.  The answer to this question is -unequivocally no,- you code what you knew at the end of the visit, in other words it was a screening Pap smear and it stays a screening Pap smear.  At the next visit, It would become the 795.01 and any further care following that, but you cannot change it because it was done as a screening Pap smear and this policy does not cover screening Pap smears.  I advised the person who asked this question however, to double-check with Blue Cross to be sure that the actual interpretation of the Pap smear was not a covered benefit; while the visit might not be, but the Pap smear should have been, I cannot envision any insurance company today not covering screening Pap smears, at least the laboratory portion, because it is a way to open up the floodgates for them for some high cost care later on if they miss the cancer.  But I also told them that if the lab had to do the HPV testing secondarily because the first one came back as that result, the laboratory can use the 795.01 diagnosis on the HPV testing portion of it that they are going to be bill for.  But they cannot use it on the original Pap smear that they did, because the purpose of it was screening.  So I hope that clarifies that.

Again, if anybody has any questions that you find and you say,  I should have remembered to ask whatever,- please fax them to us at the Coding Institute and I believe the fax number is listed in your materials and I will be more than happy to answer any questions that you have.  On July 21st, I believe it is, my next conference is going to be on multiple gestations for any of you who might be interested in coming to that one and I will also be in my new location, I am moving to New Mexico from Virginia and I will be in my new horse ranch.  So I look forward to hearing from all of you again and thank you so much.

To view the slides please refer to this issues pdf.