Ob-Gyn Coding Alert

Question: A Medicare patient who is high risk due to sexual behavior came in for her annual wellness visit. The ob-gyn did a Pap, and the office reported G0438 with Q0091. They ordered a repeat Pap six months later, due to insufficient cells. The patient came back to have the repeat Pap, but they did complain at the visit that she had urinary frequency and pain. The ob-gyn evaluated her for a urinary tract infection (UTI). How should I code the repeat Pap? Should I report it with Q0091 again?

Maine Subscriber

Answer: Yes. You should report Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the repeat Pap smear. Don’t forget to append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional). Your diagnosis will be Z12.4 (Encounter for screening for malignant neoplasm of cervix) if the first smear was inadequate.

As for the UTI, you should bill a separate evaluation and management (E/M) service (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). You should report the UTI with N39.0 (Urinary tract infection, site not specified).