Pathology/Lab Coding Alert

A Pap smear that appears abnormal requires interpretation by a physician, but some pathologists find it difficult to receive fair payment for it, especially if the payer is Medicare. Carriers often deny these claims because coders misapply one of four physician Pap interpretation codes: 88141 (cytopathology, cervical or vaginal [any reporting system]; requiring interpretation by physician [list separately in addition to code for technical service]), P3001 (screening papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician), HCPCS G0124 (screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician) or G0141 (screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician). Payment for physician interpretation of Pap smears depends on properly linking the diagnosis code, the Pap smear code and the physician interpretation code.

By understanding when and how to use these codes, pathologists should be able to ensure fair payment for their work, says Stacey Hall, RHIT, CPC, CCS-P, director of corporate coding for Medical Management Professionals Inc., a billing and practice management firm headquartered in Chattanooga, Tenn.

Pap Coding Primer

A Pap smear involves preparing cervical or vaginal cytopathology smears and reviewing them for abnormal cell changes. There are multiple technical methods for providing this service, which may be carried out by a cytotechnologist or an automated system, under physician supervision. Fourteen CPT codes and seven HCPCS codes describe it. The differences in these codes are based on lab method, reporting system and whether the Pap smear was ordered for screening or diagnostic purposes.

Regardless of which Pap smear code is reported, if the review of the slides identifies abnormal cellular changes, a physician must provide an additional service of interpreting the smear. The physician will interpret the slides and determine the diagnosis, Hall says. Regardless of whether the pathologist confirms abnormal cellular changes, he or she must write a report explaining the findings to justify the physician interpretation service.

Assigning the Correct Pap Smear Code

The first step in assigning the correct interpretation code is choosing the correct Pap smear code. If the wrong Pap smear code is assigned, the wrong interpretation code will be assigned as well, and both services will be denied, Hall says. The Pap smear codes are first based on the reason the test was ordered: as a screening test in the absence of signs and symptoms of disease, or as a diagnostic test because of signs of disease.

If the Pap smear is for screening in an asymptomatic patient, one of the HCPCS codes (P3000, G0123 or G0143-G0148) should be used, Hall says. If the Pap smear is ordered to aid in the diagnosis of a patient with signs or symptoms of disease, use the CPT codes (88142-88154, 88164-88167). Remember that the procedure code selection does not change regardless of whether the Pap results are positive or negative. For either HCPCS or CPT Pap codes, choose the code that accurately describes the laboratory technique, reporting system and screening/ rescreening method employed.

1. Screening Pap smears: Most screening Pap smears are reported with P3000 (screening papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision) or G0123 (screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision). (For a full discussion on all HCPCS and CPT Pap test codes, see How a Lab Can Avoid Medicare Denials for Pap Smears in the April 2000 issue of Pathology/Lab Coding Alert).

Remember that screening Pap tests are ordered in the absence of signs or symptoms of disease, so the appropriate diagnosis code would be one of the V codes, Hall says. In fact, Medicare requires the use of one of two codes, based on whether the patient is considered at high risk or low risk for developing cervical cancer. They are V76.2 (special screening for malignant neoplasms, cervix) for low-risk patients, and V15.89 (other specified personal history presenting hazards to health) for high-risk patients. High risk includes patients with any of the following histories: early onset of sexual activity, multiple sexual partners, history of sexually transmitted disease, having fewer than three negative Pap smears within seven years or being the daughter of a woman who took DES (diethylstilbestrol) during pregnancy.

Medicare has also established frequency limitations for administering screening Pap smears. Beginning July 1, 2001, one of those limits is changing. (See Medicare Changes Pap Screening Frequency Rules on page 47 for a description of the change.)

2. Diagnostic Pap smears: The majority of diagnostic Pap smears are reported with 88142 (cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision) or 88164 (cytopathology, slides, cervical or vaginal [the Bethesda System]; manual screening under physician supervision)

There are 12 other CPT codes describing diagnostic Pap smears using various other review methods, lab techniques and reporting systems.

Medicare covers diagnostic Pap smears for a number of reasons that represent signs and symptoms of disease. These should be reported with the appropriate ICD-9 code for conditions such as previous cancer or other abnormal findings of the cervix, uterus, vagina or ovaries; previous abnormal Pap smear; or any other finding that the physician judges to be related to a gynecological disorder.

Assigning the Correct Interpretation Code

If any screening or diagnostic Pap smear reported with any HCPCS or CPT code results in the identification of an abnormality, a physician would interpret that smear. According to Hall, deciding which code should be used for physician interpretation of an abnormal Pap smear depends on which code describes the original Pap test. Each CPT or HCPCS Pap smear code can only properly be paired with one of the Pap interpretation codes, Hall says. If you mismatch the Pap test code with the Pap interpretation code, you probably wont be paid for the interpretation.

If the interpretation is for a screening Pap, reported with a HCPCS code, then one of the HCPCS interpretation codes must be used, Hall says. A rule of thumb will help you remember this: For screening Pap smears for Medicare patients, all codes should start with letters (i.e., the V codes and HCPCS codes). Below is each of the HCPCS Pap interpretation codes, with the associated Pap smear codes:

Code P3001 (screening papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician) should be used to report physician interpretation of a Pap smear coded P3000 or G0147

Code G0141 (screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician) should be used with G0148

Code G0124 (screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician) should be reported with G0123, G0143, G0144 or G0145.

These physician interpretation services are payable in addition to the Pap screening service, so you should report both codes (e.g., P3000 and P3001) when both services are provided, Hall advises. This has been true since Jan. 1, 1999, before which time the interpretation codes were not all separately reportable.

In the same way, if the physician interpretation is for a diagnostic Pap smear reported with one of the 14 CPT Pap test codes, use 88141 (the only CPT physician Pap interpretation code). Note that 88141 is an add-on code, meaning that it is always reported separately in addition to the original Pap smear code, Hall says.

We had experienced problems in the past with Medicare denials for physician interpretation of Pap smears, reports Stan Werner, MT (ASCP), administrative director and corporate compliance officer of Peterson Clinical Laboratory in Manhattan, Kan. We were able to stop the denials by billing 88141 for interpretation following the 88164 or 88142 service, billing P3001 for interpretation following the P3000 service, and billing G0124 for interpretation following the G0123 service.