Pathology/Lab Coding Alert

Distinguish diagnostic, high-risk, low-risk.

Knowing the frequency coverage rules for screening Pap smears is all well and good -- but do you know how to legitimately "break" the rules for inadequate specimens and still get paid for the lab tests?

When your lab processes "repeat" Pap tests following an inadequate or abnormal Pap, you'll need to know the diagnosis and procedure coding tricks to make sure you get your claims paid.

Show Medical Necessity for Repeat Following Abnormal Pap

When a patient's cervical Pap smear returns abnormal results, you should report 795.0x (Abnormal Papanicolaou smear of cervix and cervical HPV). This code series requires a fifth digit, and if you don't include it, this "could be a reason for a denial," says Peggy Stilley, CPC, COBGC, ACS-OB, director of auditing services at the American Academy of Professional Coders.

Select one of the following codes to show medical necessity when the physician orders a repeat Pap test because the initial cervical Pap (either screening or diagnostic) revealed a cytologic abnormality:

• 795.00 -- Abnormal glandular Papanicolaou smear of cervix
• 795.01 -- Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)
• 795.02 -- ... cannot exclude high grade squamous intraepithelial lesion (ASC-H)
• 795.03 -- Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL)
• 795.04 -- Papanicolaou smear of cervix with high grade squamous intraepithelial lesion (HGSIL)
• 795.06 -- Papanicolaou smear of cervix with cytologic evidence of malignancy
• 795.09 -- Other abnormal Papanicolaou smear of cervix and cervical HPV.

No frequency limit: A repeat Pap test based on an initial abnormal Pap is diagnostic, not screening, because the patient shows signs and symptoms of disease. Labs face no frequency limits for diagnostic Pap tests. Time is not the key to coverage -- medical necessity is -- demonstrated by an appropriate ICD-9 code. Most Medicare and other payers provide a list of "payable" diagnoses that support a diagnostic Pap test order, and the preceding codes are typically on those lists.

Know procedure code: Reference the table on page xxx to learn your CPT® code options for diagnostic Pap tests versus screening Pap tests for Medicare beneficiaries.

Heed Rules for Repeat Following Inadequate Pap

If the physician orders a repeat Pap test because the initial diagnostic cervical Pap is inadequate, ICD-9 provides 795.08 (Unsatisfactory cervical cytology smear) to describe the findings -- but you won't always use that code. When and how to use 795.08 to bill for initial and follow-up Pap tests depends on many circumstances, discussed below.

Don't bill 'unread' inadequate Pap slides: If the lab doesn't evaluate a Pap test for reasons such as the slide is broken or unlabeled, you shouldn't bill for the original Pap test -- so you won't report 795.08.

You should charge for an unsatisfactory cervical cytology smear only when the lab fully processes the slide but cannot reach a diagnosis for reasons such as too few endocervical cells present. In those cases, use 795.08 in the following manner:

• For an unsatisfactory diagnostic Pap, bill the service with 795.08
• For an unsatisfactory screening Pap, "labs should use code 795.08 as a secondary diagnosis with the appropriate Pap screening test to indicate the cytologic service was performed but the specimen was unsatisfactory," according to CAP Today, Oct. 2004.

ICD-9 codes that Medicare requires as the primary diagnosis for Pap screening tests include the following:

• V76.2 -- Special screening for malignant neoplasms; cervix
• V76.47 -- ... vagina
• V76.49 -- ... other sites

For annual high-risk screening: V15.89 -- Other specified personal history presenting hazards to health; other

Also report a secondary diagnosis explaining the condition that places the patient in the high-risk category, such as V13.8 (History of sexually transmitted disease).

Show medical necessity for repeat: If the initial Pap was unsatisfactory and the physician orders a repeat Pap test to achieve a cytologic diagnosis, how you code to show medical necessity depends on the payer and whether the tests are for screening or diagnostic purposes, as follows:

• Medicare and other payers: For repeat diagnostic Pap test due to initial inadequate specimen, "report 795.08 as the primary diagnosis to justify that the service is medically necessary," according to CAP Today, Oct. 2004.
• Medicare: For repeat screening Pap test due to an initial inadequate specimen, report the appropriate screening "V" code as the primary diagnosis. "Medicare does not accept 795.08 for a screening Pap," says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. To avoid running afoul of Medicare's frequency limits for screening Paps, "bill the repeat screening procedure code with modifier 76 (Repeat procedure or service by same physician or other qualified health care professional)," Witt says. Otherwise, you can expect denials for screening tests billed more than once a year for high-risk patients, or once every two years for low-risk patients.
• Non-Medicare payers: Many non-Medicare payers will pay for a repeat screening Pap following an inadequate initial screening with diagnosis code 795.08 to show medical necessity -- contact your payer for instructions.

Decipher 795.07 Transformation Zone Impact

Many insurers won't pay for a follow-up Pap test when billed with 795.07 (Satisfactory cervical smear but lacking transformation zone). That's because you should list 795.07 only as an additional diagnosis when the Pap findings are abnormal.

When the initial Pap results in abnormal findings, the ICD-9 code for cytologic abnormality (such as 795.02), not 795.07, would demonstrate medical necessity for a repeat Pap.

Hormonal impact: Because Pap smears typically sample from the transformation zone where cytologic changes indicative of cancer often occur, 795.07 provides additional clinical information to the physician. For instance, a post-menopausal woman may have no endocervical cells in the transformation zone, but based on her hormonal status, the Pap smear may still be satisfactory.