Pathology/Lab Coding Alert

Medicare has refined coding for screening Pap smears for patients who have had a hysterectomy. Coders were in a quandary under the old rules because reimbursement for a screening Pap smear required either a high-risk or a cervical diagnosis code, even if the patient was without the risk factors and without a cervix. Medicare has added a third, noncervical diagnosis code that allows payment of screening Pap smears for women who have none of the high-risk factors and have had a hysterectomy.

Screening and Diagnostic Pap Smears

 
Medicare's coverage rules for Pap smears distinguish between diagnostic tests ordered for patients with signs and symptoms of disease and screening tests for asymptomatic patients. "The only way the laboratory knows if the Pap smear is a diagnostic or screening test is for the physician to identify it correctly," says Elizabeth Sheppard, HT (ASCP), manager of Anatomic Pathology at Wake Forest University Baptist Medical Center in Winston Salem, N.C. "That's why it is important for labs to educate physicians about these rules.
 
"Report diagnostic Pap smears with the appropriate CPT procedural code (88142-88154 or 88164-88167) based on the testing methodology," Sheppard says. However, coders should report screening Pap smears using the appropriate HCPCS code (P3000, G0123 or G0143-G0148). For both CPT and HCPCS test codes, choose the code that accurately describes the lab technique, reporting system and screening/rescreening method employed.
 
"Don't be confused by the codes' use of the terminology 'screening and rescreening,' " Sheppard warns. The description of a Pap smear's being "screened and rescreened" refers to the cytotechnologist's or automated system's observation of the slide to identify potentially abnormal cells and the possible rescreening by a pathologist. "This is different from Medicare's use of the term 'screening Pap smear,' which refers to conducting any of the testing methodologies in the absence of signs and symptoms of disease," Sheppard says.

Medicare Rules for Screening Pap Smears

 
"In order for Medicare to cover a screening Pap smear, certain rules regarding testing frequency and diagnosis coding must be met," Sheppard says. Medicare categorizes patients as "high-risk" or "low-risk," and coverage frequency varies accordingly. "If a screening Pap smear is ordered at a frequency greater than allowed by Medicare, labs must be sure to have an advance beneficiary notice (ABN) on file so they can bill the patient for the service," Sheppard says.
 
Medicare covers a screening Pap smear for high-risk women of childbearing age once a year. Patients at high risk for cervical cancer are those with any of the following histories: early onset of sexual activity, multiple sexual partners, history of sexually transmitted disease, having fewer than three negative Pap smears within seven years or being the daughter of a woman who took DES (diethylstilbestrol) during pregnancy.
 
For these cases, Medicare's direction is to use V15.89 (other specified personal history presenting health hazards) as the diagnosis code.
 
Beginning July 1, 2001, Medicare covers screening Pap smears for low-risk patients once every two years. Prior to that date, the tests were covered once every three years. In the past, Medicare required coders to use V76.2 (special screening for malignant neoplasms, cervix) as the reason for the Pap screening for all low-risk women, even if they had previously had a hysterectomy.

Pap Smears for Women With Hysterectomies

 
"Medicare's requirement that all screening Pap smears be reported with either V76.2 or V15.89 created a dilemma for coders," says Melanie Witt, RN, CPC, MA, independent coding educator and former program manager for ACOG's department of coding and nomenclature. "Which diagnosis code do you report for a patient who doesn't have any of the risk factors to justify code V15.89 or for a patient who doesn't have a cervix to justify code V76.2? If laboratories wanted reimbursement for these procedures, they were essentially required to record a diagnosis code that may not accurately reflect the patient's condition." 
 
However, CMS amended the coverage rules in the Medicare Carriers Manual (transmittal number 1675) to allow the use of V76.49 (special screening for malignant neoplasms, other sites) for a patient who does not have a uterus or cervix.
 
"Unfortunately, HCFA [now CMS] didn't select the most specific diagnosis code available to describe screening Pap smears for women with hysterectomies,"  Witt says. "The more specific code would be V76.47 (special screening for malignant neoplasms, vagina)." Direction in the ICD-9 manual clarifies that V76.47 is for "Vaginal Pap smear status -- post-hysterectomy for non-malignant condition. Use additional code to identify acquired absence of uterus (V45.77). Excludes vaginal Pap smear status -- post-hysterectomy for malignant condition (V67.01)." 
 
"At least the use of V76.49 doesn't require a misleading diagnosis for women with hysterectomies, but it is still less specific than reporting code V76.47," Witt  says. "However, for Medicare reimbursement for screening Pap smears, coders must report one of the codes, V15.89, V76.2 or V76.49." Although there are a number of secondary-diagnosis codes that can be used on the claim form for a screening Pap smear, one of these three codes must be used for Medicare coverage. 

ACOG Says Pap Tests May Be Unnecessary

 
"Ironically, the American College of Obstetrics and Gynecology (ACOG) recently released a news brief calling attention to a study in the August 2001 issue of Obstetrics & Gynecology that calls into question the value of Pap smears for women who have had hysterectomies,"  Witt says. "Although the study does not have immediate implications for the coding of screening Pap smears, it may impact coverage policies in the future."
 
The study was based on a review of data from several national databases. Researchers from the Centers for Disease Control and Prevention (CDC) say women who have had the uterus and cervix removed for noncancerous conditions (over 80 percent of hysterectomies) are at low risk for cervical cancer and do not need Pap screenings.
 
The ACOG news release states, "Researchers estimate that between 10.6 million and 11.6 million of the 12.5 million women with hysterectomies in the U.S. receive Pap tests that they don't need. The estimated cost to the healthcare system over a three-year period for these unnecessary Pap tests ranges from $375 million to $505 million."