Pathology/Lab Coding Alert

Question: What type of diagnosis is acceptable to bill a pathologist’s review of an abnormal Pap smear, and can we bill 88141 if the pathologist’s findings are normal?

Louisiana Subscriber

Answer: When a Pap screening test results in a determination (by cytotechnologist or automated review) that the smear show cellular changes, the pathologist will examine the slide(s) and report final findings to report 88141 (Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician). The pathologist’s interpretation service is billable even if the findings are negative.

Some payers have local coverage determinations (LCDs) listing specific ICD-10-CM codes for abnormal Pap screening findings that warrant a pathologist’s interpretation, so you should see if your Medicare Administrative Contractor (MAC) has such a policy.

Aside from an LCD, various authoritative sources such as CMS, AMA CPT^® guidance, and the College of American Pathologists (CAP) have weighed in on what cellular changes warrant pathologist review. These include the following, with possible ICD-10-CM codes:

• reparative/reactive cellular changes, such as due to radiation, viral infection, etc. (R87.618)
• atypical endocervical, endometrial, or glandular cells not otherwise specified (R87.619)
• atypical squamous cells of undetermined significance (ASCUS, R87.610)
• atypical squamous cells, cannot exclude high grade squamous intraepithelial lesion (ASC-H, R87.611)
• low- or high-grade squamous intraepithelial lesion (LGSIL R87.612, or HGSIL R87.613)
• HPV-positive patient, high or low risk (R87.810, R87.820).

Essentially, if screening personnel determine that the Pap test is abnormal or suspicious and refer it for pathologist’s interpretation, which the pathologist completes and issues a report, you can bill the 88141 service.