Pathology/Lab Coding Alert

Reason, frequency make or break claims

You can't call the shots when a physician assigns a Pap smear ordering diagnosis. But you can learn how that diagnosis drives your procedure coding -- and when you need to get a signed ABN.

Distinguish Screening and Diagnostic

To select the proper diagnosis or procedure Pap codes, you need to answer this question: Is the test for diagnostic or screening purposes? Physicians order screening Pap tests at regular intervals for patients who have no signs or symptoms of disease.

"If a patient presents with symptoms or a personal history that indicates a need for the test, the Pap smear is a diagnostic test," says Melanie Witt, RN, CPC-OGS, MA, a coding expert based in Guadalupita, N.M.

Results don't matter: "Remember that a Pap test is either screening or diagnostic based on the reason the physician ordered the test, regardless of the results," Witt says.

Hidden trap: For Medicare patients, the reason for the test drives CPT coding -- not just ICD-9 coding.

Watch Risk Level to Facilitate Screening Pay

Medicare covers screening Pap tests more often for patients at high risk for developing cervical cancer than for patients at low risk. That's why you need to know how ICD-9 codes indicate risk.

Low risk: For Medicare patients at low risk, you can report a Pap smear only once every two years. The diagnoses your physician should use when ordering a test for low-risk patients include the following:

- V72.31 -- Routine gynecological examination

- V76.2 -- Special screening for malignant neoplasms; cervix

- V76.47 -- Special screening for malignant neoplasms; vagina

- V76.49 -- Special screening for malignant neoplasms; other sites.

Medicare indicates that you may use V76.47 or V76.49 for a post-hysterectomy patient without a cervix.

High risk: If the patient is high-risk, you can bill the Pap smears annually. To classify a patient as high-risk, use V15.89 (Other specified personal history presenting hazards to health; other).

But the ordering physician should also supply a secondary diagnosis to explain why the patient is high-risk. The diagnoses include:

- History of HIV (V08 or 042)

- History of sexually transmitted diseases (V13.8)

- Five or more sexual partners (V69.2)

- Began sexual activity before 16 years of age (V69.2)

- Diethylstilbestrol (DES) exposure (760.76)

- Seven years without a Pap smear (V15.89)

- Absence of three consecutive negative Pap results (795.0x)

- Any gynecological problem (such as cervical or vaginal cancer or genitourinary system problem) in the last three years if the patient is of childbearing age.

Know when to use ABN: If the screening Pap test exceeds Medicare's frequency limits for the patient's risk category, the lab should have a signed advance beneficiary notice (ABN) on file. You should have an ABN when the patient's insurer won't cover a test because you cannot prove medical necessity, says Lena Robins, JD, senior counsel at Foley and Lardner LLP -- and that includes frequency limits.

Choose screening procedure code: Make sure to use the appropriate HCPCS procedure code that corresponds to the type of test the lab performs.

Billable codes for screening Pap tests for Medicare beneficiaries include:

- P3000 -- Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision

- G0123 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

- G0143 -- Screening 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

- G0145 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision

- G0147 -- Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

- G0148 -- Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening.

Diagnostic Paps Take Different Codes

Physicians order diagnostic Pap smears based on symptoms or disease history. CMS states that a Pap smear is diagnostic if the patient has one of the following conditions:

- previous cervical, uterine or vaginal cancer that a physician has treated or is treating

- previous abnormal Pap smear

- abnormal findings of the vagina, cervix, uterus, ovaries or adnexa

- a significant complaint concerning the female reproductive system

- signs and symptoms that the physician relates to a gynecologic disorder.

Report diagnostic Pap tests using these codes:

- 88142 -- Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

- 88143 -- - with manual screening and rescreening under physician supervision

- 88147 -- Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision

- 88148 -- - screening by automated system with manual rescreening under physician supervision

- 88150 -- Cytopathology, slides, cervical or vaginal; manual screening under physician supervision

- 88152 -- - with manual screening and computer-assisted rescreening under physician supervision

- 88153 -- - with manual screening and rescreening under physician supervision

- 88154 -- - with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

- 88164 -- Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

- 88165 -- - with manual screening and rescreening under physician supervision

- 88166 -- - with manual screening and computer-assisted rescreening under physician supervision

- 88167 -- - with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

- 88174 -- Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision

- 88175 -- - with screening by automated system and manual rescreening or review, under physician supervision.

Caution: "Don't let the words -screening- and -rescreening- in the definitions confuse you," Witt says. The terms refer to the examination and re-examination of the slides, not to the reason for the test.