Pathology/Lab Coding Alert

Follow these 5 steps to improve your Pap reimbursement

With more than two dozen procedure codes, different coverage rules for screening versus diagnostic tests, and changing diagnosis coding requirements, you've got a lot to keep track of when reporting cervical cancer lab tests. "But you can minimize claim denials if you report Pap and ancillary tests according to the following five steps," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Professional Coding and Compliance Consulting in Manassas, Va.

1. Determine if Pap Test Is for Screening

Physicians order screening Pap tests at regular intervals for patients with signs of disease. "If a patient presents with symptoms or a personal history that indicates a need for the test, the Pap smear would not be considered screening," says Melanie Witt, RN, CPC, MA, an independent coding educator based in Fredericksburg, Va.
 
Medicare has established coverage rules for screening Pap tests that many other payers follow regarding frequency and test type. Coding is often different, however, because Medicare prescribes specific HCPCS Level II codes for its screening exams. See the table on page 92 for a complete list of the codes.
 
The rules for screening Pap tests distinguish between high-risk and low-risk patients. Medicare covers Pap screening for low-risk patients once every two years, and high-risk patients once a year. Medicare considers patients who have any of the following documented risk factors to be high-risk: early onset of sexual activity, multiple sexual partners, history of sexually transmitted disease, fewer than three negative Pap smears within the previous seven years, and daughters of women who took DES (diethylstilbestrol) during pregnancy.
 
Based on risk level, you should report one of four diagnosis codes to designate the reason for the Pap screening. Report V15.89 (Other specified personal history presenting hazards to health; other) for annual screening Pap smears for high-risk patients. For biennial Pap smears for low-risk patients, report V76.2 (Special screening for malignant neoplasms; cervix), V76.47 (Special screening for malignant neoplasms; vagina), or V76.49 (Special screening for malignant neoplasms; other sites). Medicare has indicated that you may use either V76.47 or V76.49 for patients who are post-hysterectomy for a nonmalignant condition.

2. Use Different Codes for Diagnostic Pap

Physicians order diagnostic Pap smears based on symptoms or disease history. "Remember that a Pap test is either screening or diagnostic based on the reason the physician ordered the test, regardless of the results," Witt says.
 
A wide range of ICD-9-CM codes may indicate medical necessity for diagnostic Pap tests, including conditions such as a prior abnormal Pap (795.09, Other nonspecific abnormal Papanicolaou smear of cervix) or history of cervical dysplasia (622.1, Dysplasia of cervix [uteri]).
 
Report the diagnostic Pap test procedure using the appropriate CPT code found in the table on page 92. "Do not use the HCPCS Level II codes for diagnostic Pap tests - those are for screening tests only," Witt says.

3. Report the Lab Method

Once you've decided whether you're reporting a CPT code for a diagnostic test or a HCPCS Level II code for a Medicare screening test, you should select the code based on the lab method, the screening and rescreening method, and the reporting method.
 
"Don't let the words 'screening' and 'rescreening' in the definitions confuse you," Castillo says. "Those terms don't mean it's a screening test - they simply refer to the examination and re-examination of the slides."
 
The two common cervical cytology lab methods are "thin layer preparation" and conventional Pap smears, referred to in the definitions as "slides" or "smears." Multiple CPT and HCPCS Level II codes describe each of these lab methods, with the codes distinguished by the screening and rescreening method (such as manual or automated) and the reporting system (such as Bethesda). Refer to the table on page 92 for a complete list of cervical cytology codes.

4. Bill Professional Interpretation for Abnormal Paps

If the cytotechnologist or automated system identifies abnormal findings for any Pap test, a pathologist must then interpret the slides. The pathologist's interpretation is a separately reportable professional service. "You have to choose one of the four Pap interpretation codes, based on the original technical code," Witt says.
 
Report add-on code 88141 if the pathologist interprets any abnormal diagnostic Pap test reported with codes 88142-88154, 88164-88167, or 88174-88175 (see code definitions on the table on page 92). For physician interpretation of an abnormal screening thin layer Pap, report G0124 in addition to the technical service code, G0123 or G0143-G0145. If the physician interprets an abnormal screening P3000 Pap test, also report P3001 for the interpretation. For screening Paps reported with G0147-G0148, report the pathologist's interpretation of abnormal findings with G0141.
 
"Remember that you should never change the technical Pap code based on the findings," Witt says. "If a screening Pap identifies abnormal cells, you shouldn't change the code to a diagnostic code; you should report the additional professional service code."

5. Code HPV if Medically Necessary

Lab HPV testing is becoming more common in the diagnosis and treatment of cervical cancer. In its guidelines issued in fall 2002, the American Society for Colposcopy and Cervical Pathology recommended HPV testing for patients whose Pap test returned results classified as atypical squamous cells of undetermined significance (ASCUS) or higher. Some payers and carriers consider an abnormal Pap a payable diagnosis for HPV testing. For instance, First Coast Florida Medicare lists 795.00-795.09 (Nonspecific abnormal Papanicolaou smear of cervix ...) as payable diagnoses in its LMRP for 87621 (Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique).
 
Now the American College of Obstetricians and Gynecologists (ACOG) recommends less frequent cervical cancer screening using combined HPV and Pap testing for women over 30, rather than more frequent Pap testing alone. See "New Guidelines Could Mean Fewer Paps in Your Lab's Future" on page 93 of this issue for the complete story on the ACOG guidelines. "To ensure coverage, you should research your payers' rules for HPV testing before reporting the service," Witt says.