Ob-Gyn Coding Alert

A spate of recent publications that discuss coding for Medicare's G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) contained some conflicting information. CMS now has issued new information that addresses those discrepancies.

The American College of Obstetricians and Gynecologists' (ACOG) new, comprehensive Medicare screening guide (available at ftp://ftp.acog.org/coding/ medicare.doc) indicates that providers can use code V76.49 (Special screening for malignant neoplasms; other sites) as a diagnosis code linked to Q0091 when the patient does not have a uterus and therefore the Pap is actually a vaginal specimen. An article in the October 2001 Ob-Gyn Coding Alert titled "Risk Factors Rule Well-Woman Exams" also indicates that V76.49 is an acceptable code to use with the Pap collection code Q0091. We recently have become aware that many Medicare carriers are not accepting the V76.49 diagnosis code for Q0091 Pap smear collection or the Pap smear interpretation.

Some local carrier policies follow the exact wording found in the Medicare Carriers Manual (MCM) (Section 4603.1), and others have presented the information in a different format, says Melanie Witt, RN, CPC, MA, an independent coding educator and ob/gyn coding expert who serves as consulting editor for Ob-Gyn Coding Alert. The problem is that the MCM information indicates that V76.49 would be used instead of V76.2 (Special screening for malignant neoplasms; cervix) for the pelvic exam (G0101) but also includes a section titled "diagnosis coding" that implies that V76.49 would be used with the Pap collection and interpretation codes as well. "It was for this reason that I wrote to CMS to inquire about the discrepancy," Witt says.

CMS' response, from Claudette Sikora of the Provider Billing and Education Group of CMS, explains the agency's perspective on the policies. Sikora writes that CMS' national systems currently are set up to look for a diagnosis of either V76.2 or V15.89 (Other specified personal history presenting hazards to health; other) to help verify the medical necessity of a screening Pap smear (Q0091 for the collection or P3000 or P3001 for the interpretation). "The manual discusses what our systems will look for as an appropriate diagnosis code for these services but is not intended to instruct providers as to which diagnosis code to use." Her memo to Witt implied that CMS is aware, however, of some confusion this printed policy may cause because carriers are reading the section and interpreting that V76.2 and V15.89 are the only codes that can accompany Q0091. Sikora indicated that CMS would not disregard the possible need for such a diagnosis of V76.49 for screening Pap smears, "and we are looking into the matter."

In the meantime, if you perform a vaginal Pap on a woman who has had a hysterectomy, diagnosis code V76.2 (every two years for the low-risk patient) or V15.89 (every year for the high-risk patient) must be linked to the collection code Q0091, while V76.49 (low-risk, no uterus) or V15.89 would be linked to the pelvic/breast exam code G0101 for the same date of service.