Pathology/Lab Coding Alert

Question: How should we report the pathologist's service if a cytotechnologist identifies a Pap smear as "possible atypical cells" but the pathologist's final diagnosis is normal? Can we still bill for the pathologist's interpretation?

Maryland Subscriber

Answer: Regardless of the final diagnosis, you can bill for the pathologist's evaluation of a Pap identified through screening as possibly abnormal. Select the proper code based on the reason for the test and the initial screening method. If the physician ordered the Pap for diagnostic purposes based on the patient's signs and symptoms, the Pap screening would be reported with one of the CPT Pap codes (88142-88154 and 88164-88167). Then the pathologist would report the interpretation using +88141 (Cytopathology, cervical or vaginal [any reporting system]; requiring interpretation by physician [list separately in addition to code for technical service]).

On the other hand, if the doctor ordered the original Pap as a preventive service in the absence of signs or symptoms of disease, you'd use the appropriate HCPCS Level II code based on the lab method used. These codes are G0124 (Screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician), G0141 (Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician) or P3001 (Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician).