Ob-Gyn Coding Alert

In the ob/gyn setting, Pap smears rarely have to be repeated because of an insufficient number of cells on the first slide. But repeating a routine process like this raises several questions: Whose fault is it that the test has to be repeated, how should the repeat test be coded and who should absorb the cost of the subsequent visit? Does the patient pay for the repeat procedure, or is the cost of the second sample absorbed by the practice?

Coding the Sequence

If a Pap test needs to be repeated because there are too few cells collected to conduct the appropriate screenings, it usually is not due to a codeable medical condition or physician error. Very often, especially with postmenopausal women, the endocervical lining from which the cells are scraped has grown thin. If the lining has thinned to the point that the initial sampling does not capture enough cells, the laboratory cannot perform the required screenings of the cells, and a second Pap smear has to be taken.

Assuming that the first Pap smear was taken as part of a preventive medicine or annual well-woman exam, the initial visit would be coded using preventive medicine evaluation and management (E/M) codes for a new or established patient, most likely codes 99385-99387 (initial preventive medicine evaluation and management of an individual including a comprehensive history, a comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, new patient) depending on age, or 99395-99397 for an established patient, also depending on age.

For the well-woman visit, the diagnostic code would be V72.3 (gynecological examination), which includes taking the Pap smear specimen. This scenario also assumes that the physician or practice uses the services of an outside laboratory, rather than performing the Pap smear interpretation in house. The laboratory would bill for the cytopathology, or testing of the smears, using the 88141-88199 (cytopathology, cervical or vaginal ... ) group of codes, depending on the screening methods used.

If the laboratory is unable to complete the necessary screenings due to insufficient cells on the slide, they will notify the practice. The practice then will have the patient return for another Pap smear. For this repeat collection, an established patient E/M code would be used, most likely 99212 (office or other outpatient visit for the evaluation of an established patient ... including a problem focused history, a problem focused examination and straightforward medical decision-making). The repeat visit is coded at a level two because the more comprehensive history, examination and medical decision-making likely took place at the initial visit.

Diagnosis Coding for the Repeat Pap

When billing for the second office visit to collect the repeat Pap, practices will need to demonstrate the medical necessity of the visit. Emily Hill, PA-C, president of Hill & Associates, a medical coding and compliance consulting firm based in Wilmington, N.C., warns coders not to misidentify the reason for the repeat Pap with the wrong diagnostic code. Ive heard of coders trying to use ICD-9 code 795.0 (nonspecific abnormal Papanicolaou smear of cervix), says Hill, but this sends the wrong signal to the carrier. Using this code gives the patient a record of having an abnormal Pap smear, which is not correct if the only problem is that there were not enough cells to make a determination. The Pap smear should not be interpreted as abnormal, but rather unable to determine based on the insufficient cells collected. The problem is with the number of cells, not the cells themselves, she continues. Therefore, you would not want to have the patient record to read as if there was an abnormality if one truly does not exist. You are merely repeating a screening exam in the absence of any abnormal findings. When a patient is asked to return for a Pap smear due to an insufficient number of cells collected on the initial smear, the proper diagnosis would be V76.2, (special screening for malignant neoplasms, cervix), says Hill.

To Bill or Not to Bill

Asking the patient to return for another visit and Pap smear collection raises the question of billing who pays for the repeat procedure? Melanie Witt, RN, CPC, MA, an independent coding educator, reminds coders and physicians that for the repeat procedure, office space, staff time and equipment are still being used, and generally the practice should not be expected to absorb that cost. Having to do a repeat Pap is almost never a question of technique, says Witt. The only reason a practice might feel obligated to absorb the cost is if the physician or other clinical staff did not take the sample right the first time. But Witt explains that the repeat screening is most often due to lack of cells in the endocervical lining, not physician error. If the practice did the work, says Witt, whether it was one time or two, they should bill the patient or the carrier for all the work that was done.

When submitting billing for the repeat Pap, Witt agrees that V76.2 is the appropriate diagnostic code to use, assuming there is nothing else wrong with the patient. The carrier initially may reject the second claim for the E/M visit, but explaining to the carrier that there was an insufficient number of cells on the first test likely will result in payment. Although this obviously will vary from carrier to carrier, because the practice is billing for a relatively low-level E/M service, reimbursement for the second office visit should not be too much of a challenge.

You are creating another E/M service so the physician can collect more cells, says Witt. Its fairly straightforward. The documentation submitted with the second claim should easily support a level-two visit. Be sure to include any correspondence with the laboratory that indicates that the first slide contained an insufficient number of cells.