Pathology/Lab Coding Alert

To decide which diagnosis code to report for screening Pap smears, you must first determine the patients risk level. Based on whether the patient is at high or low risk for developing cervical cancer, Medicare has established different frequency limitations for screening Pap smears. Medicare covers Pap screening for low-risk patients once every two years, and high-risk patients once a year.

Medicare considers patients who have any of the following documented risk factors to be high-risk: early onset of sexual activity, multiple sexual partners, history of sexually transmitted disease, fewer than three negative Pap smears within the previous seven years, and daughters of women who took DES (diethylstilbestrol) during pregnancy. Diagnosis V15.89 is the only code Medicare accepts for screening Pap smears performed annually for high-risk patients, but you may add a second code for the condition that meets one of the above criteria as well.

Medicares Oct. 1 implementation will soon relieve the coding dilemma youve dealt with for years: how to report screening Pap smears for low-risk patients who have previously had a hysterectomy. "These patients have no cervix, but Medicare required that you report V76.2, which effectively states that the patient has a cervix," Witt says. Coders thought this problem was solved once before when Medicare published transmittal 1675 (Aug. 31, 2000) adding V76.49 for cervical cancer screening. The transmittal wording appeared to clear code V76.49 for screening pelvic exams as well as screening Pap smears.

But when labs began using V76.49 for screening Pap smears, carriers didnt pay. "Many labs were told by their carriers that V76.49 is only for use with screening pelvic exams, not Pap smears," says Elizabeth Sheppard, HT, (ASCP), manager of Anatomic Pathology at Wake Forest University Baptist Medical Center in Winston Salem, N.C.

This time there can be no question about using the additional diagnosis codes for screening Pap smears. Program memorandum AB-03-054 clearly states that its purpose "is to add the diagnosis codes for low-risk patients to the common Working File edits for Pap smear and pelvic examinations. The two additional diagnosis codes for low risk are V76.47 and V76.49."

So which diagnosis code should you report for screening Pap smears performed for low-risk women post-hysterectomy? "Code V76.47 better describes the screening Pap smear for a woman without a cervix because the physician typically takes the smear from the vagina," Witt says.

Medicares instructions state, however, that "V76.49 has been added for providers to use for women without a cervix." Sheppard suggests that you contact your local provider to clarify this discrepancy. "Its good news that Medicare says it will accept both V76.47 and V76.49," Sheppard says. "But you should contact your carrier or intermediary to see if they prefer one code or the other for posthysterectomy Pap smears."

"If the physician orders a screening Pap smear more frequently than allowed under Medicare rules, you must know whether or not the ordering physician obtained an advance beneficiary notice (ABN) so that you can report the test with the proper modifier," Sheppard says. If you have an ABN for a screening Pap smear ordered more frequently than covered by Medicare, append modifier -GA (Waiver of liability statement on file) so you can bill the patient for the service. If you do not have an ABN for a Pap test that exceeds frequency limitations, append modifier -GZ (Item or service expected to be denied as not reasonable and necessary) to avoid the appearance of fraud.