Pathology/Lab Coding Alert

Question: The lab performed a liquid-based Pap test that the physician ordered, which we billed to Medicare as G0144. The claim was denied because it turns out the patient had a prior Pap test nine months ago. How can we get paid for the test?

Washington Subscriber

Answer: The payer was correct to deny a claim for a screening Pap test within nine months based on frequency limitations for screening. That’s why you may not be able to get paid for the test. But if you analyze the following two details of the case, you might have a path to reimbursement.  

First: Did the physician order the Pap test as a screening or diagnostic test? If the physician ordered the test based on signs or symptoms such as an abnormal finding on the patient’s last Pap test, then it is a diagnostic test and therefore not subject to the same frequency restrictions. In that case, you would need to document the appropriate diagnosis code, such as R87.619 (Unspecified abnormal cytological findings in specimens from cervix uteri). Additionally, you should not bill the test using code G0144 (Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision). Instead, you should resubmit the claim with the correct procedure code for a diagnostic Pap test, such as 88174 (Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision).

Second: If the physician did indeed order a screening Pap test using a diagnosis code such as Z12.4 (Encounter for screening for malignant neoplasm of cervix), then you are subject to the frequency limitations and the test is not covered. In that case, your only hope for payment is if you have a signed advance beneficiary notification (ABN), which indicates that the patient is aware the test may not be covered and that she will be responsible for payment. If you do have a signed ABN, you need to append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) to the test code. Having the signed ABN should allow you to bill the patient for the test.