Ob-Gyn Coding Alert

Adhere to standard ACOG, ASCCP, and CMS protocol.

A subscriber like you wrote in to the Ob-gyn Coding Alert editor to ask a question about the article, "Quick Tips: Untangle Your Well-Woman Exam Coding With This Advice," featured on page four of the 2001, volume 14, number A issue, which describes Medicare high risk coding.

This article describes one of the high risk elements as the "absence of three consecutive negative Pap results" while Medicare phrases this as "fewer than three negative Pap smears within the previous seven years."

"The Coding Institute's interpretation, to me, sounds like one abnormal Pap smear and the patient qualifies for high-risk -- which is true for childbearing patients but not non-child-bearing women," points out Silah Patterson, CPC, COBGC, coding manager for Women's Health USA in Avon, Connecticut. Is this correct?

Key: For postmenopausal women, fewer than three negative Pap smears within a seven year time period qualifies her as high-risk -- but fewer than three negative Pap smears within three years qualifies a childbearing aged woman as high-risk.

Follow This Explanation

The standard protocol for abnormal Pap smears to revert back to a screening Pap smear is three consecutive normal Paps after an abnormal Pap smear. This is part of published information by both American Congress of Obstetricians and Gynecologists (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP). You'll find that this protocol is in keeping with Medicare high risk guidelines.

The CMS provider manual states that a high risk element includes "fewer than three negative or any Pap smears within the previous seven years ..." (emphasis added). You can interpret this to mean the patient has not had three consecutive negative Pap smears and is therefore in the high risk group, per the standard protocol.

Additionally, the Ob-gyn Coding Alert article includes the phrase "any Pap smears within the previous seven years" based directly on the wording in the CMS manual.

Follow These Rules for Childbearing Age

For women who are of childbearing age, the criteria for high risk includes that she had a Pap smear test during any of the preceding three years that indicated the presence of cervical or vaginal cancer or other abnormality. This too goes along with the standard medical protocol of performing yearly Paps until the patient has had three consecutive negative Pap results.

In other words, if in Year 1, a patient has an abnormal Pap smears but previous Pap smears have been normal. The ob-gyn repeats the Pap smear every six months for the latter part of Year 1 and over the course of Year 2 (each of these three Pap smears coded as diagnostic, not screening). All three come back normal. That means that she goes back to low risk screening in Year 3.

Now, suppose the same patient undergoes these three Pap smears, and the first and second come back normal but the third comes back abnormal. Now, she has not had three consecutive normal Pap smears. She is therefore eligible under the high risk screening rules -- until she has had three consecutive normal Pap smear results.

Heads up: Do you have a burning question you'd like to ask the editor? Get the answer by emailing suzannel@codinginstitute.com.