Pathology/Lab Coding Alert

Align 'medical necessity' with ICD-9 instruction.

Ordering a human papillomavirus (HPV) screen with a Pap test isn't the same as ordering a reflex HPV screen following an abnormal Pap. Although ICD-9 instruction and coverage rules might appear to be at loggerheads, our experts can show you the way out.

Question: Should the physician order a screening and/or reflex HPV Pap test (such as 87621, Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique) with V73.81 (Special screening examination for human papillomavirus [HPV])?

What you stand to gain: "Many 'V' codes are paid as part of a screening benefit for patients who have those specific benefits," says Tina Burkhalter, billing manager with SouthEastern Pathology in Rome, Ga. On the other hand, "tests ordered with diagnostic codes tend to go to the deductible," she says. "We hear from patients complaining that they must pay for the HPV test because their insurer tells them we used the 'wrong' code."

Medical Necessity Points to 795.0x

Although no national coverage policy exists for screening HPV testing to evaluate cervical cancer risk, many payers follow the consensus guidelines recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP).

A core ASCCP recommendation is to screen for high-risk HPV DNA in patients over the age of 20 years with a Pap cytologic result of 795.01 (Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASCUS]).

The guidelines also address the role of HPV with other Pap outcomes in special populations, such as recommending reflex HPV testing for postmenopausal women with cytologic findings of 795.03 (Papanicolaou smear of cervix with low grade squamous intraepithelial lesion [LGSIL]).

Key: If your payers have adopted any or all of these guidelines, you'll need to report the Pap findings, such as 795.01, to show medical necessity when the lab "reflexes" the specimen to a high-risk HPV screen, such as 87621, following abnormal Pap.

For instance: National Government Services has a local coverage determination (LCD) that points you to 795.00, 795.01, or 795.02, when appropriate, to show medical necessity for 87621 (available online at www.cms.gov/mcd/viewlcd.asp?lcd_id=29508&lcd_version=9&show=all).

"Historically, the recommendation for labs has been to use the abnormal Pap findings (795.xx) as the ordering diagnosis for a reflex HPV screening test," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of the Pathology Service Coding Handbook, in The Villages, Fla. ICD-9 Directs You to V73.81

The screening gynecological exam code (V72.31, Routine gynecological examination) used to serve for HPV test orders -- but no more. ICD-9 added a text note: "Use additional code to identify: human papillomavirus (HPV) screening (V73.81).

Similarly, a note following screening Pap test code V76.2 (Routine cervical Papanicolaou smear) states "excludes special screening for human papillomavirus (V73.81)." Those instructions indicate that you should use V73.81 to order a screening HPV test in addition to a Pap test if the ordering physician wants the HPV test run regardless of the Pap test result. Sort Out the Instructions How can you manage these two HPV test-order options to legitimately maximize coverage?

Scenario 1: "Some physicians are ordering HPV screening with every Pap test for women 30 years or older," Burkhalter says. "Note that Medicare does not provide a screening benefit for HPV."

In this scenario, the lab would report V76.2 for the Pap test, plus a secondary diagnosis for any abnormal findings. Additionally, "when the physician specifically orders a screening HPV test, the lab should report V73.81 plus a secondary diagnosis if the result is positive (such as 795.05, Cervical high risk human papillomavirus [HPV] DNA test positive)," says Melanie Witt, RN, CPC, COBGC, MA, a coding expert based in Guadalupita, N.M.

Scenario 2: "More commonly, physicians order a Pap test with a request to reflex to an HPV screening if the Pap results are AS-CUS," says Burkhalter.

"In this case, the lab bills V76.2 for the Pap test, and if findings are AS-CUS, additionally reports 795.01 as the secondary diagnosis on the Pap specimen. Then the lab reports 795.01 for the HPV test (if it is negative), or reports a result such as 795.05 (if it is positive)," Witt advises.

Options: If reporting V73.81 means no patient deductible based on a private insurer's policy but the physician orders a reflex HPV for AS-CUS results, what can you do? "I'd suggest reporting 795.01 as the primary code and V73.81 as the secondary code on a claim for HPV screening following an AS-CUS positive Pap," Padget says. "Or if your billing computer allows you to report V73.81 as the primary diagnosis on select insurers, that would be great. Basically, you'd be following the explicit instructions of each specific insurer, which couldn't be considered a compliance violation."