Ob-Gyn Coding Alert

Question: We code our Pap smears, HPVs, colpo's and LEEPs with the diagnosis that has been determined by previous tests or by what is found at the time of service. We've been holding the billing until we receive the path report. We would like to continue to charge the patient at the time of service and proceed with billing. What should we do?

Arkansas Subscriber

Answer: You are coding correctly. You should only report what you know at the end of the visit. 

For example, if the patient comes in for a screening Pap, your diagnosis at the time of the service will be a "screening" diagnosis, V72.32, which will include both the exam and the screening Pap smear, if the ob-gyn performs them.

If you then learn that this Pap was abnormal and the ob-gyn must ask the patient to come back for follow-up, the diagnosis at that visit will be the abnormal result, for instance, 795.01, ASC-US.

Suppose the Pap you take at that visit should turn out negative (as sometimes happens with ASC-US results), but you ask the patient to come back for another Pap. The diagnosis for that visit will be V72.32 (Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear). 

This same principle applies to any Pap smear result: Code what you know at the end of the visit.