Ob-Gyn Coding Alert

Question: What is the correct ICD-9 and CPT code for a Pap smear that needs to be repeated for inadequate sampling?

Florida Subscriber

Answer: If your office does not perform the lab component of a Pap smear and you are really asking how to code for the visit in which a repeat Pap smear was obtained, the answer depends on the insurance carrier involved. For Medicare, use Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the office visit.

Other payers use 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making). Documentation criteria would be met in the key components of exam and medical decision-making. Your provider must document a problem-focused exam (one body area or organ system) and straightforward decision-making (repeat of Pap smear due to inadequate sampling). Link diagnosis code V76.2 (routine cervical Pap smear) with the service.