Pathology/Lab Coding Alert

Question: What ICD-9 code should we use to report a Pap test with -normal- results?

Texas Subscriber

Answer: ICD-9 doesn't have a specific code for normal Pap test results. Instead, you should report a normal Pap test with the ordering diagnosis. When you report the reason for the test as the only diagnosis, you-re stating, effectively, that you do not have any abnormal findings to report.

Do this: For a screening Pap test with normal findings, you should report the appropriate screening code, such as one of 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.

Or this: For a diagnostic Pap, you should report the sign or symptoms that prompted the order for a Pap test. For instance, you might report a prior abnormal Pap, such as 795.01 (Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]), or bleeding unrelated to menstruation (626.6, Metrorrhagia).

Or this: The physician might order a diagnostic Pap for an asymptomatic patient based on a personal or family history using an ICD-9 code such as V71.1 (Observation for suspected neoplasm). If the Pap is normal, you would use this code to report the results.