Pathology/Lab Coding Alert

Medicares directives for reporting Pap smears can be confusing, but understanding and complying with the rules is the key to appropriate reimbursement. Selecting the correct code depends on knowing the reason for the test, as well as the lab methods used, states Paula Richburg, BS, MHA, director of laboratory services at QuadraMed Corp, a healthcare information technology firm in Bethlehem, Penn.

The first question you need answered is whether the Pap smear is ordered for screening or diagnostic purposes, says Richburg. Medicare explicitly states that the code selection is always based on the reason the test was performed, regardless of the results of the test (Health Care Financing Administration [HCFA] program memorandum AB-98-71). The answer to this question will lead to two different groups of codes, she continues. Pap smears conducted by the same method and reporting system will have a different code depending on the purpose for the test, she concludes.

Diagnostic vs. Screening Pap Smears

When a Pap smear comes to the lab, the only way to know if its for diagnostic or screening purposes is to have the ordering physician tell you, says Mary Lou Fusillo, MT (ASCP), MS, MPA, laboratory manager at North Shore University Hospital, in Manhasset, N.Y. Thats why weve revised our protocol and changed our requisition form for Pap smears, she continues. The form requires an ICD9 Codes assignment by the physician, which points us in the direction of the screening or diagnostic codes.

The difficulty arises because although the physician assigns the diagnosis code, HCFA holds the lab responsible for making sure that the code meets Medicare coverage criteria, continues Fusillo. The solution, discussed in the Office of Inspector Generals (OIG) Compliance Program Guidance for Clinical Laboratories, is for labs to provide their physician clients with information regarding Medicare criteria for Pap smears.

The Medicare criteria for Pap smears center on the reason for the test, which is reflected in the selection of appropriate ICD-9 codes, states Fusillo. According to Medicare, screening Pap smears are those that are performed in the absence of signs or symptoms of disease. Medicare covers these once every three years, or more often if the patient is considered at high risk for cervical or vaginal cancer.

Because screening Pap smears have a frequency limitation for reimbursement, it is wise to get an Advance Beneficiary Notice (ABN) signed by the patient if the physician hasnt already done so, advises Fusillo. By signing the ABN, the patient agrees to pay for the service if the claim is denied. Then the lab can bill the patient if he or she has had a Pap smear more recently than allowed by Medicare criteria.

Diagnosis Codes for Screening Pap Smears

For reimbursement of screening Pap smears, Medicare requires the indication of patient risk level, Richburg explains. This is accomplished by using ICD-9 code V76.2 (special screening for malignant neoplasm; cervix) for low-risk patients, or V15.89 (other specified personal history presenting hazards to health; other) for high-risk patients, she continues. Although a number of appropriate secondary diagnosis codes can be used on the claim form for a screening Pap smear, either V76.2 or V15.89 must be used to indicate risk, according to HCFA.

A high-risk assessment is based on the presence of at least one of several history possibilities, which include early onset of sexual activity (before 16 years of age), multiple sexual partners (five or more), or history of sexually transmitted disease. The other factors considered high risk are having fewer than three negative Pap smears within seven years or being the daughter of a woman who took DES (diethylstilbestrol) during pregnancy.

Codes for Screening Pelvic Exam and Pap Smear

The ICD-9 code that the physician submits to the lab with the request for Pap evaluation is the same code used to report the pelvic exam and collection of the specimen. HCPCS code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) is the procedure code for a screening pelvic exam, states Richburg. The Pap smear may be collected during the same patient encounter and can be reported as a separate line item on the claim using HCPCS code Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), she reports.

After the slides are received in the lab with the
ICD-9 code (G0101) that indicates the slides are from a screening Pap smear, selecting the procedure code depends on the laboratory methods used, declares Fusillo.

The appropriate codes for screening Pap smears are all HCPCS codes, she continues. For any conventionally prepared Pap smear that initially goes through a manual screening process, code P3000 (screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision) should be used.

This code is reported regardless of the rescreening method (manual, computer assisted, or cell selection) or reporting system (Bethesda or non-Bethesda).

If the P3000 service identifies abnormalities that require physician interpretation of the slides, the pathologist reports P3001 (screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician) for that service. Code P3001 also should be used for physician interpretation of a screening Pap smear for which the method of specimen preparation, evaluation and reporting system is not specified.

Editors note: Effective Jan. 1, 1999, P3001 became a professional code only and is no longer reported with modifiers -TC (technical component) and -26 (professional component), according to HCFA.

Use code G0147 (screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision) for an automated screening of a conventionally prepared Pap smear, suggests Richburg. If the screening identifies abnormalities, use code P3001 to report a pathologists interpretation of the slides.

If an automated screening is manually rescreened, the appropriate code is G0148 (screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening), Richburg continues. The correct code for pathologist interpretation of these slides, if required, is G0141 (screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician).

Richburg says that HCPCS has a series of codes for screening Pap smears processed by thin-layer preparation, depending on the method of screening and rescreening:

G0123screening cytopathology, cervical or
vaginal (any reporting system), collected in preser-
vative fluid, automated thin layer preparation,
screening by cytotechnologist under physician
supervision;

G0143screening 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;

G0144screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision; and

G0145screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision.

If a pathologist interpretation code is required, G0124 (screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician) is the appropriate code for all of the thin-layer preparation Pap smears.

Codes for Diagnostic Pap Smears

Medicare covers diagnostic Pap smears for a number of reasons that represent signs and symptoms of disease, advises Richburg. These include previous cancer or other abnormal findings of the cervix, uterus, vagina or ovaries; previous abnormal Pap smear or any other finding that the physician judges to be related to a gynecological disorder.
The appropriate ICD-9 code for the condition should be reported, and all diagnostic Pap smears should be coded with CPT procedural codes, continues Richburg.

Appropriate CPT code selection depends on slide preparation technique, screening method and reporting system. For a full discussion of these codes, see Cut Through the Confusion of Pap Guidelines on page 6 in the January issue of Pathology/Lab Coding Alert.

For appropriate Medicare coverage of Pap smears, be sure to obtain appropriate diagnosis information from the ordering physician to determine if it is a screening or diagnostic Pap smear, advises Richburg. Then select the HCPCS or CPT code that best describes the testing methods used.