Pathology/Lab Coding Alert

Reason for repeat is key.

Coding for Pap tests is complicated enough, but coding for repeat Pap tests is even more confusing. 

Follow our expert advice to make sure that your repeat Pap test claims show the proper ICD-9 and procedure codes — or your lab could get stuck holding the bag for the cost of the test.

Tip 1: Determine Reason for Repeat

Physicians typically order repeat Pap tests for one of two reasons — either the original Pap was “inadequate,” or the original Pap was “abnormal.” You need to know the difference, because correct coding for the repeat Pap depends on it.

Inadequate: If the lab fully processes the slide but fails to reach a diagnosis because too few endocervical cells are present, that’s an inadequate Pap test. In that case, the lab would bill for the original test, having fully preformed the service. A repeat Pap ordered because the original test is inadequate is still considered a screening test. That means it’s still subject to frequency limitations that the second test will probably exceed. Read the next two tips to learn some coding magic to show medical necessity for this type of repeat test.

Caveat: If the lab fails to complete the original Pap test for reasons such as a broken or improperly labeled slide, then you shouldn’t bill for the original Pap. You would then bill the second Pap just as you would have billed the original test. 

Abnormal: If the lab finds cellular changes to endocervical cells in the original Pap specimen, the test result is abnormal. The type and degree of cellular changes will lead to different diagnoses, and the clinician will decide on a follow-up protocol based on those findings. Sometimes, the follow-up involves repeating the Pap test in a few months. The repeat Pap test in these circumstances is no longer a screening test, but is instead a diagnostic test.  

Tip 2: Choose the Right Dx Code

Depending on whether the original Pap test was inadequate or abnormal, you’ll use different diagnosis coding strategies to make sure your lab gets paid for the second test. You’ll also need to consider the payer when choosing the diagnosis code, because different payers want you to handle the situation differently. 

Inadequate: If the clinician orders a second Pap within the screening frequency limit because the initial test is inadequate for diagnosis, many payers want you to bill the second test with diagnosis code 795.08 (Unsatisfactory cervical cytology smear). 

Medicare is different: If the patient is a Medicare beneficiary and you’re billing a repeat Pap following an inadequate Pap, you should use the same diagnosis code you would use for the original screening test, such as V76.2 (Special screening for malignant neoplasms; cervix). “Medicare does not accept 795.08 for a screening Pap,” says Melanie Witt, RN, CPC, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

Abnormal: If the initial Pap test identifies abnormal cells, the appropriate diagnosis code may be one of the following:

• 795.00 — Abnormal glandular Papanicolaou smear of cervix
• 795.01 — Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)
• 795.02 — Papanicolaou smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)
• 795.03 — Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL)
• 795.04 — Papanicolaou smear of cervix with high grade squamous intraepithelial lesion (HGSIL)
• 795.06 — Papanicolaou smear of cervix with cytologic evidence of malignancy
• 795.09 — Other abnormal Papanicolaou smear of cervix and cervical HPV.

If the clinician determines that a repeat Pap test is appropriate, the ordering diagnosis will be the findings from the initial test, such as one of the above codes.

Ordering a follow-up Pap test with one of the preceding codes “denotes a diagnostic Pap smear, not a screening Pap smear,” says Jan Rasmussen, PCS, CPC, ACS-OB, ACS-GI, president of Professional Coding Solutions in Eau Claire, Wis.

That means the follow-up Pap test after initial abnormal findings is not subject to frequency limitations. The key to coverage for diagnostic Pap tests is medical necessity, not frequency. Most payers accept one of the above ICD-9 codes as a payable diagnosis for a repeat Pap test following abnormal findings. 

Tip 3: Choose the Right Procedure Code

Choosing the proper Pap procedure code depends primarily on the lab and reporting methods used, such as liquid cytology versus direct smears, manual versus computer assisted slide processing, and reporting method, such as Bethesda. That’s why you have 14 CPT® codes to choose from for the technical Pap test, such as 88142 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, manual screening under physician supervision).

Given the level of complexity in choosing a Pap code, you might think that whether the physician orders the Pap test for screening or diagnostic purposes wouldn’t impact the procedure code choice. But you would be wrong, at least if Medicare is the payer.

Here’s why: If your lab performs a screening Pap test for a Medicare beneficiary, you should not use any of the CPT® codes, but should instead choose one of the seven HCPCS Level II codes that describe technical screening Pap tests, 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). 

Why it matters for repeat Paps: Remember that if a clinician orders a repeat Pap due to an inadequate specimen, the new test is still considered a screening Pap. But if the clinician orders a repeat Pap due to abnormal findings in the original Pap, the new test is considered a diagnostic Pap. 

Because Medicare requires different procedure codes for diagnostic and screening Pap tests, you’ll use a different procedure code depending on the reason the clinician orders the repeat Pap.

Problem: If the repeat Pap is due to an inadequate specimen on the initial Pap, you’ll report a procedure code such as G0123 to Medicare for the repeat test. But if you’re performing the test within a year of the initial test for a high risk patient, or within two years of the initial test for a low-risk patient, you’ll run afoul of Medicare’s screening benefit frequency rules, and you can expect a denial.

Solution: To report the preceding scenario, you need to use a modifier to avoid an automatic denial based on frequency edits. “Bill the repeat screening procedure code with modifier 76 (Repeat procedure or service by same physician or other qualified health care professional),” Witt says.