Ob-Gyn Coding Alert

Learn the 2 key concepts of well-woman exams

A physician routinely performs Papanicolaou, or -Pap,- smears for female vaginal and cervical screening during annual well-woman visits, but the doctor may also do them for diagnostic reasons. The procedure entails collecting a cell sample from the vagina or cervix and spreading it on a glass slide or transporting it to the lab in a preservative fluid.

For Medicare patients at low risk, you can report a Pap smear only once every two years. The diagnoses your physician can use when billing include the following:

- V72.31 -- Routine gynecological examination

- V76.2 -- Special screening for malignant neoplasm, cervix

- V76.47 -- Special screening for malignant neoplasm, vagina

- V76.49 -- Special screening for malignant neoplasm, other sites.

Use V76.49 for women without a cervix.

If the patient is high-risk, you can bill the Pap smears annually. To classify a patient as high-risk, use (V15.89, Other specified personal history presenting hazards to health; other).

Your physician should supply a secondary diagnosis to explain why the patient is high-risk. The diagnoses include:

- History of HIV (V08 or 042)

- History of sexually transmitted diseases (V13.8)

- Five or more sexual partners (V69.2)

- Began sexual activity before 16 years of age (V69.2)

- Diethylstilbestrol (DES) exposure (760.76)

- Seven years without a Pap smear (V15.89)

- Absence of three consecutive negative Pap results (795.0x)

- Any gynecological problem (such as cervical or vaginal cancer or genitourinary system problem) in the last three years if the patient is of childbearing age.

Make sure to use the appropriate HCPCS procedure code that corresponds to the type of test the physician performs.

Billable codes paid under the Medicare Physician Fee Schedule include:

- Q0091 -- Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory.

- P3000 -- Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision

- P3001 -- Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician

- G0101 -- Cervical or vaginal cancer screening; pelvic and clinical breast examination

- G0123 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

- G0124 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by requiring interpretation by physician

- G0141 -- Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician

- G0143 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision

- G0145 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision

- G0147 - Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

- G0148 -- Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening.

Codes G0123, G0143, G0147, G0148 and P3000 are payable by the Part B carrier for procedures done in the office, ambulatory surgical center and independent laboratory.

Codes G0124, G0141 and P3001 are payable by the Part B carrier for procedures that take place in the office, inpatient/outpatient hospital, ambulatory surgical center and independent laboratory.

Q0091 is payable only when the procedure takes place in the office and ambulatory surgical center.

Q0091 is paid under the Physician Fee Schedule and, therefore, the Part B deductible for this service is waived because of the specific waiver provision.

Keep Well-Woman Exam Claims Squeaky Clean

To code a well-woman exam correctly, you-ve got to know two key concepts: how Medicare and private payers- guidelines differ, and when you should separately code breast/pelvic exams and Pap smears.

When the physician provides complete well-woman exams (a pelvic exam, breast exam and Pap smear) for Medicare patients, report G0101 and Q0091, and link them to V76.2 for low-risk patients or V15.89 for high-risk patients.

Important: You can report a new or established patient E/M code (99201-99215) in addition to G0101 and Q0091, providing the physician documents a separate and distinct E/M service. Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code in this case. You can bill G0101 on the same date as a screening Pap smear.

For example: The physician performs a well-woman exam for a Medicare patient, but also evaluates and manages the patient's ongoing dysfunctional uterine bleeding.

Exception: Sometimes the lab determines that a Pap smear is insufficient for evaluation, and the physician must obtain a second specimen before the frequency limitation period of one or two years is up. That's when you need to use modifier 76 (Repeat procedure by same physician) to bypass the frequency edits for Q0091.

Coding scenario: The Medicare patient requests that your physician perform only a Pap smear during an exam.

In this scenario, you can bill Q0091, but you can't report V72.31 because the physician didn't conduct a complete exam. Instead, you should report V76.2.

You should always get the patient to sign an advance beneficiary notice (ABN) when the physician performs a Pap smear sooner than the frequency limitations allow -- or if the patient doesn't remember when her last Pap spear occurred -- because Medicare will deny the claim. The ABN indicates that the patient is responsible for that portion of the bill Medicare doesn't pay.

Tip: Use a GA modifier (Waiver of liability statement on file) on the claim to indicate you have the signed ABN.

Physicians almost always include a Pap smear as part of the well-woman examination for non-Medicare patients. Although the woman hasn't reported a problem, the doctor performs the test as part of a comprehensive preventive medicine service. This includes obtaining the sample and making the slide.

What you should do: In this case, you should report of the preventive medicine codes (99384-99387 for new patients and 99394-99397 for established patients). This includes the reimbursement for the Pap smear collection.
 
The insurance carrier will determine whether it will cover the service because reimbursement depends on the patient's policy.

In some cases, private payers will reimburse for handling the Pap specimen. If so, you can also report 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory). Typically, you-ll link V72.31 to 99000.

You should only use 99000 if the physician incurs a cost for handling the specimen.

Diagnostic Pap Smears Require Separate Codes

CMS states that a Pap smear is diagnostic if the patient has one of the following conditions:

- previous cervical, uterine or vaginal cancer that a physician has or is treating

- previous abnormal Pap smear

- abnormal findings of the vagina, cervix, uterus, ovaries or adnexa

- a significant complaint concerning the female reproductive system

- signs and symptoms that the physician relates to a gynecologic disorder.

Example: The physician sees a new pregnant patient and performs a Pap smear in addition to the exam.

The Pap smear is not related to the pregnancy, so if your physician performs only the Pap smear, you provide the link (V76.2) to the lab that does the interpretation. Keep in mind that carriers rarely pay separately for the Pap specimen collection on the first visit.

If your physician performs a separate and significant preventive annual exam at the time of this visit, you can use the preventive medicine codes (99381-99387 for a new patient or 99391-99397 for an established patient). You should link the diagnosis V72.31 to the preventive E/M service.

Red flag: You must remember to separate V72.31 from the pregnancy diagnosis (such as V72.42, Pregnancy confirmed) and show that V72.31 relates only to an annual preventive exam.

Your physician then sends the Pap to a laboratory qualified under the federally mandated Clinical Laboratory Improvement Amendments (CLIA) for interpretation and reporting. The laboratory pathologist then reports her services using the following CPT codes:

- 88141 -- Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician

- 88142 -- Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, manual screening under physician supervision

- 88143 -- ... with manual screening and rescreening under physician supervision

- 88147 -- Cytopathology smears, cervical or vaginal, screening by automated system under physician supervision

- 88148 -- ... screening by automated system with manual rescreening under physician supervision

- 88150 -- Cytopathology, slides, cervical or vaginal; manual screening under physician supervision

- 88152 -- ... with manual screening and computer-assisted rescreening under physician supervision

- 88153 -- ... with manual screening and rescreening under physician supervision

- 88154 -- ... with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

- +88155 -- Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (e.g., maturation index, karyopyknotic index, estrogenic index) (list separately in addition to code[s] for other technical and interpretation services)

- 88160 -- Cytopathology, smears, any other source, screening and interpretation

- 88161 -- ... preparation, screening and interpretation

- 88162 -- ... extended study involving over 5 slides and/or multiple stains

- 88164 -- Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

- 88165 -- ... with manual screening and rescreening under physician supervision

- 88166 -- - with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

- 88167 -- ... with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

- 88172 -- Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s)

- 88173 -- ... interpretation and report

- 88174 -- Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision

- 88175 -- ... with screening by automated system and manual rescreening or review, under physician supervision

- 88182 -- Flow cytometry, cell cycle or DNA analysis

- 88184 -- Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker

- +88185 -- ... each additional marker (list separately in addition to code for first marker)

- 88187 -- Flow cytometry, interpretation; 2 to 8 markers

- 88188 -- ... 9 to 15 markers

- 88189 -- ... 16 or more markers

- 88199 -- Unlisted cytopathology procedure.

Use These ICD-9 Diagnosis Codes

The lab interprets the Pap smear and reports the results back to the physician. Use the following codes for lab reporting and interpretation:

- 795.00 -- Abnormal glandular Papanicolaou smear of cervix

- 795.01 -- Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)

- 795.02 -- Papanicolaou smear of cervix with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H)

- 795.03 -- Papanicolaou smear of cervix with low- grade squamous intraepithelial lesion (LGSIL)

- 795.04 -- Papanicolaou smear of cervix with high- grade squamous intraepithelial lesion (HGSIL)

- 795.05 -- Cervical high-risk human papillomavirus (HPV) DNA test positive

- 795.06 -- Papanicolaou smear of cervix with cytologic evidence of malignancy 

- 795.08 -- Unsatisfactory smear

- 795.09 -- Nonspecific finding NEC

- 795.1 -- Nonspecific abnormal finding Papanicolaou smear of other site.

Example: The lab submits 795.09 to report a low-risk human papilloma virus (HPV) DNA test positive. In addition, you should code for HPV (079.4) to indicate the nonspecific finding.

Track Pap Smear Technology to Choose Codes

CPT 2006 clarifies the difference between -review- and -rescreening- and allows 88175 to pay the same for both services.

Based on the old code definition, some labs were unsure if they could report 88175 when they used the Cytyc ThinPrep Imaging System for Pap test evaluation.

Because the cytotechnologist does not always rescreen the entire slide, some argued that 88175 did not describe this automated imaging system that selects 22 fields for manual review.

Update: For 2006, adding -or review- to the 88175 code definition clarifies that it is the appropriate code, even for tests that do not rescreen the entire slide. To further clarify the difference between rescreening and review, CPT 2006 added the following direction at the beginning of the cytopathology section:

-Manual rescreening requires a complete visual reassessment of the entire slide initially screened by either an automated or a manual process. Manual review represents an assessment of selected cells or regions of a slide identified by initial automated review.-

ThinPrep example: A physician sends a cervical brush and scraping in a vial with preservative fluid to the lab for evaluation. The lab uses an automated system to prepare a liquid-based ThinPrep slide. The ThinPrep Imaging System then scans the slide and identifies the 22 most significant fields for manual review.

The cytotechnologist examines the 22 fields and identifies no atypical cells. You should report this service as 88175.

Distinguish Liquid-Based Paps

CPT 2006 also added language in the cytopathology section to distinguish -conventional- and -liquid-based- Pap tests. Conventional Pap smears involve the physician scraping cells from the cervix and fixing them immediately on a slide for later evaluation at the lab.

Liquid-based Pap tests, on the other hand, involve the physician brushing or scraping cells into a liquid preservative, which the lab then processes with an automated system into a -thin layer- or -monolayer- slide. Thin-layer preparations have the advantage of spreading the cells out, making them easier to visualize than on thicker, conventional Pap smears.

Here's the coding difference: The new cytopathology instructions specify that 88150-88154 and 88164-88167 describe conventional Pap smears, while you should use 88142-88143 and 88174-88175 for thin-layer preparation Pap smears.

Know the Bethesda Difference

The cytopathology section introduction for CPT 2006 also contained language about Bethesda vs. non-Bethesda reporting systems. Bethesda does not describe a lab method; rather, it is a way of reporting findings from Pap tests using any lab method.

If the lab uses the Bethesda system, the report will include a statement of specimen adequacy and possibly a general categorization, such as -negative for intraepithelial lesion or malignancy.- If the Pap shows abnormalities, the report will also include an interpretation using specific categories such as atypical glandular cells (AGC), atypical squamous cells of undetermined significance (ASC-US), atypical squamous cells -- high grade (ASC-H), etc. Finally, the report includes a statement of review and ancillary testing, if any.

Pap smear codes that specify the Bethesda reporting system include 88164-88167. Pap smear codes that state -any reporting system- may use Bethesda, but not necessarily. These include all the thin-layer preparation codes: 88142-88143 and 88174-88175. You can only use the following codes for non-Bethesda, conventional Pap tests: 88147-88154.

Watch Out for Modifier Indicator

There are National Correct Coding Initiative (NCCI) edit pairs that prohibit reporting certain codes together, and you will get a denial if your payer uses the NCCI edits.

Example: A physician sends two specimens from a single patient to the lab: a Pap smear and a urine for cytology because the patient has blood in her urine. The lab performs an automated thin-prep Pap exam that requires manual rescreening, and a urine concentration and cytology exam.

The proper code for the Pap smear is 88175 for most payers, including Medicare if this is a diagnostic Pap smear that the physician ordered due to specific symptoms. If this is a screening Pap smear for a Medicare patient who has no symptoms, however, the proper code is G0145.
 
The proper code for the concentrated urine cytology exam is 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]).

Watch out: Do not report 88175 and 88108 together.The point of the 88175/88108 edit pair is to prohibit labs from reporting both a thin-layer Pap smear and a cytology concentration for the same Pap specimen. If you have two distinct specimens, you should be able to report both services.

CMS lists each NCCI edit pair with a -modifier indicator- that tells you if you can use a modifier, such as 59 (Distinct procedural service), to override the edit pair when medical necessity warrants reporting the bundled services together. In the case of the 88175/88108 bundle, NCCI lists a modifier indicator of -0,- meaning you cannot override the edit pair. Effectively, you cannot get paid for these two services when the lab performs them for the same patient on the same day.