Ob-Gyn Coding Alert

Question: I am confused when it comes to reporting diagnosis codes for repeat Pap smears. Could you tell me what the difference is between an abnormal finding and unsatisfactory smear?

Virginia Subscriber

Answer: For an abnormal finding, you should use R87.61- (Abnormal cytological findings in specimens from cervix uteri…) as the diagnosis code if the ob-gyn repeats the Pap smear due to abnormal results. This code requires a sixth character. If you don’t include the sixth character, this could be a reason for a denial.

For example, a 35-year-old woman with multiple sexual partners presents for an annual exam. She has not had a Pap smear in four years. The Pap results return ASCUS favoring benign, and the physician asks her to come back in four months for a repeat Pap to follow any abnormal cell progress. When the patient returns, you should code the appropriate E/M office visit with R87.610 (Atypical squamous cells of undetermined significance on cytologic smear of cervix [ASC-US]) because the Pap is repeated due to abnormal cells.

How to code for inadequate samples: On the other hand, if the patient requires a second Pap smear because the first sample was inadequate (that is, the lab did not have enough cells in the specimen to interpret the results), you should report R87.615 (Unsatisfactory cytologic smear of cervix).

For example, the ob-gyn misses the cervical opening when taking a Pap smear because the patient is obese. The Pap result indicates the absence of endocervical cells, and the physician likely would require another Pap. In this case, you would submit the second Pap screening with R87.615, assuming this is not a Medicare patient.

When this occurs with the Medicare patient, your diagnosis code changes to Z12.4 (Encounter for screening for malignant neoplasm of cervix) or Z77.9 (Other contact with and [suspected] exposures hazardous to health) if the patient was considered high risk. But remember, Medicare will require you to bill this repeat Pap using code Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) rather than an E/M service, because Medicare still considers this to be a screening.

And since you are repeating it, you should add modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional) to this Q code.