Ob-Gyn Coding Alert

Question: Please explain more about coding for Medicare's high-risk categories for screening Pap and pelvic exams. Does a history of breast cancer (or any other cancer) qualify a patient as high-risk for cervical or vaginal cancer?

Colorado Subscriber
 
Answer: Medicare does not consider breast cancer a risk factor for vaginal or cervical cancer. It will only accept the risk categories that it specifies, which include:

  onset of sexual activity under 16 years of age (V69.2, High-risk sexual behavior)
  five or more sexual partners in a lifetime (V69.2)
  personal history of specified diseases (V13.8, Personal history of other specified diseases)
  absence of three negative Pap smears (795.0, Nonspecific abnormal Papanicolaou smear of cervix)
  history of HIV (V08, Asymptomatic HIV infection status; or 042, HIV)
  absence of any Pap smears within the previous seven years
  prenatal exposure to diethylstilbestrol (DES), commonly referred to as a DES daughter (760.76, Noxious influences affecting fetus via placenta or breast milk; diethylstilbestrol [DES]). 
If the patient does not meet any of these criteria, then she is not eligible for a screening Pap, pelvic and breast exam every year.
 
If the physician believes that the Pap is not a screening but, rather, is diagnostic, the physician may collect the Pap specimen every year at the time of a covered E/M service.
 
In that case, collection code Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) cannot be billed since the purpose of the Pap is not screening, and the collection becomes part of the problem E/M service being billed.