Ob-Gyn Coding Alert

Discover how private payers and Medicare differ when it comes to collection.

If your patient’s Pap smear results return as abnormal or display insufficient cells, the ob-gyn will probably perform a repeat smear. Here’s the crux: you need to use proper E/M coding to get the payment you deserve.

Focus on Your 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 $45 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 1.27 relative value units (1.27 RVUs x 2019 conversion factor 36.0391 = $45.77).

Bill Collection Under These Criteria

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), says Jan Rasmussen, PCS, CPC, ACS-OB, ACS-GI, president of Professional Coding Solutions in Eau Claire, Wis.

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.

Next, Isolate 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 sixth digit, points out Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor for a practice in Norman, Okla. If you don’t include the sixth digit, this “could be a reason for a denial,” she adds.

Example: A 32-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 what the provider knows about the patient’s condition at the time of the repeated Pap.

Solve This Inadequate Samples Scenario

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 the 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,” Stilley says. “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.