Pathology/Lab Coding Alert

Don’t confuse screening vs. diagnostic tests.

After reading the questions on page 11, now is the time to see if you’ve mastered the ins and outs of Pap test coding. Here are the answers, according to our experts:

Solution 1: The denial probably came because the ordering diagnosis gives no indication that the patient is high risk, and you exceeded the 2-year frequency limitation for screening Pap tests. However, Medicare and most other payers will cover screening Pap tests once every year if the patient is considered “high risk,” so with proper documentation, this test should becovered.

You’ll need to ask the ordering physician to specify the high risk sexual behavior that triggered her to order a screening Pap test earlier than Medicare and other payers typically cover. Then you’ll need to resubmit the claim with the appropriate diagnosis codes.

Remember: Screening means that the physician orders the test in the absence of signs or symptoms of the disease. This is still a screening test if the patient hasn’t had any signs or symptoms such as an abnormal Pap.

The conditions that Medicare considers valid to justify higher frequency screening Pap tests include the following, some of which relate to high-risk sexual activity:

• Early onset of sexual activity (under 16 years of age)
• Multiple sexual partners (five or more in a lifetime)
• History of sexually transmitted disease (including HIV infection)
• Fewer than three negative or any Pap smears within the previous seven years
• DES (diethylstilbestrol) exposure of daughters of women who took DES during pregnancy.

Here are some of the diagnosis codes that ICD-10 provides to describe these conditions:

• Z72.51 (High risk heterosexual behavior)
• Z72.52 (High risk homosexual behavior)
• Z72.53 (High risk bisexual behavior)
• Z20.2 (Contact with and [suspected] exposure to infections with a predominantly sexual mode of transmission)
• Z86.19 (Personal history of other infectious and parasitic diseases).

Bottom line: Ask the ordering physician to identify the high-risk sexual behavior factor, and assign one of the preceding codes or other appropriate code along with the screening Pap test ICD-10 code Z12.4 (Encounter for screening for malignant neoplasm of cervix). Select the appropriate procedure code that your payer accepts to describe the Pap test method your lab performs, such as G0123 (Screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision) for Medicare, or 88142 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision) for other payers that don’t recognize the HCPCS Level II Pap codes.

Solution 2: You should report the diagnosis from the earlier abnormal Pap as R87.61- (Abnormal cytological findings in specimens from cervix uteri…) as the ordering diagnosis. This code requires a sixth character, points out Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor in Norman. If you don’t include the sixth character, this “could be a reason for a denial,” she adds.

For instance: If the last Pap resulted in a diagnosis of ASC-US, you should report R87.610 (Atypical squamous cells of undetermined significance on cytologic smear of cervix [ASC-US]) as the ordering diagnosis for the repeat test. Note that this is now a diagnostic test, not a screening test, so you should not additionally report the screening code Z12.4 (Encounter for screening for malignant neoplasm of cervix).

Choose by method: You must always select the procedure code based on the lab method used for the test. Because this is a diagnostic test, you should not use one of the HCPCS Level II procedure codes that Medicare requires for screening Pap tests, even if Medicare is the payer in this scenario. Choose the appropriate CPT^® code such as 88174 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision).

Match test and interpretation: You stated that the pathologist had to interpret this test, which warrants an additional code for a separate interpretation service. “Because you’ve billed one of the CPT^® Pap test codes, the appropriate interpretation code is 88141 (Cytopathology, cervical or vaginal [any reporting system], requiring interpretation by physician),” explains R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.

However, if this had been a screening test that you reported with a HCPCS Level II code, you would choose a different interpretation code such as one of the following, which matches the initial test:

• G0124 (Screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician).
• 3001 (Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician)
• G0141 (Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician).

Solution 3: 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 need to “report the appropriate diagnosis,” says Shannon McKendall, CPC with TUMG Business Services, which is R87.615 (Unsatisfactory cytologic smear of cervix).

Unsatisfactory smear: Several conditions can result in a Pap smear that does not yield enough cells for the cytopathologist or automated system to reach a determination. For example, the physician may not reach the transformation zone to acquire enough cervical cells, or the lab analyst may not be able to see enough cells due to contamination from blood, inflammation, or mucous. When the Pap test results in an inadequate specimen for analysis, the physician likely would require another Pap. In the absence of an abnormal diagnosis, the repeat Pap would still be a screening test, not a diagnostic test.

Remember: If Medicare is the payer, you’ll need to avoid CPT^® Pap test codes and instead use one of the HCPCS Level II codes to report the screening procedure, such as G0143 (Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision).

Use modifier: Repeating a screening Pap test more frequently than allowed by coverage rules can result in a denial. To alert your payer that the repeat test is medically necessary, you’ll need to bill the second screening procedure code with a modifier. Different payers may expect different modifiers in this scenario, but many Medicare payers and others accept 76 (Repeat procedure or service by same physician or other qualified health care professional). You may want to contact your payer for instruction.