Pathology/Lab Coding Alert

Question: Because our lab has no way of knowing whether a patient has exceeded Medicare's frequency limitation for Pap smears, should we obtain a signed advance beneficiary notice (ABN) from every Pap smear patient? Under which circumstances should we use modifier -GA, indicating that we don't think the test will be covered?

Texas Subscriber

Answer: Medicare's frequency rules for Pap smears apply only to screening tests that are conducted without signs or symptoms of disease. If the Pap smear is ordered due to presenting symptoms such as abnormal vaginal bleeding (626.6, Metrorrhagia), the test is a diagnostic service and is reported with a CPT code such as 88142 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision). When this test is ordered with a payable diagnosis, regardless of the date of the last Pap smear, an ABN is not required.

However, labs need to be concerned with ABNs when conducting screening Pap smears. These tests are conducted in the absence of signs or symptoms and are covered by Medicare once every 24 months for low-risk patients, and once every 12 months for high-risk patients. High-risk patients have one of the following histories: 1) early onset of sexual activity, 2) multiple sexual partners, 3) history of sexually transmitted disease, 4) having fewer than three negative Pap smears within seven years, or 5) being the daughter of a woman who took DES (diethyl-stilbestrol) during pregnancy.

Screening Pap smears are reported to Medicare using HCPCS Level II codes such as G0123 (Screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision) rather than CPT codes. Medicare requires one of two ICD-9 codes for screening Pap smears: V76.2 (Special screening for malignant neoplasms; cervix) for low-risk patients or V15.89 (Other specified personal history presenting hazards to health; other) for high-risk patients.

Note: Although Medicare Carriers Manual section 4603.3 indicates the use of a third code, V76.49 for screening Pap smears for low-risk patients who have previously had a hysterectomy, many local carriers are denying payment for Pap smears reported with V76.49. See "Report V76.2 for Post-Hysterectomy Pap Smears to Ensure Reimbursement" in the May 2002 Pathology/Lab Coding Alert on page 33.

For the vast majority of screening Pap smears, the lab has no way of knowing for sure that the patient has not exceeded Medicare's frequency limitations. In these cases, it is prudent to obtain a signed ABN stating that the patient understands that Medicare probably will not pay for the test and that the patient will be responsible for the cost. Although the referring physician should obtain the ABN, the lab must have a copy on file. The lab should report the Pap procedure code, such as G0123, with modifier -GA (Waiver of liability statement on file).

If the lab fails to obtain an ABN but believes that the patient may have exceeded frequency limitations for a screening Pap smear, G0123 or another appropriate procedure code should be reported with modifier -GZ (Item or service expected to be denied as not reasonable and necessary). Labs should avoid this scenario because they will have to write off the expense of such tests. However, if the lab is certain that the patient has had a Pap smear paid within the past 24 months (or 12 months for high-risk patients), the service will be statutorily noncovered, and an ABN is not required. The lab reports G0123 or other procedure with modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit).

Reader Questions and You Be the Coder were answered and/or reviewed by R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.; and Kenneth Wolfgang MT (ASCP), CPC, CPC-H, member of the national advisory board of the American Academy of Professional Coders and director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa.