Ob-Gyn Coding Alert

Question: Patient had a colpopexy on 1/25/20 that came back as CIN III. Doctor performed LEEP on 2/17/20, and the path result is now CIN I. Because I am billing from the surgical pathology report, should I use CIN I? When she returns for the repeat Pap in four months, will it be CIN I instead of CIN III?

Tennessee Subscriber

Answer: You should use the Dx of cervical intraepithelial neoplasia (CIN) CIN III (D06.-, Carcinoma in situ of cervix …) for the loop electrode excision procedure (LEEP), as this is why you ob-gyn performed it. A Dx of CIN I (N87.0, Mild cervical dysplasia) may not support the medical necessity of a LEEP procedure, so payment might be an issue.>

The next time the patient comes in, you should report a Dx of CIN I (N87.0), as this is what you know at the time of the repeat Pap.