Pathology/Lab Coding Alert

Less than a year after implementation of a Medicare ruling that promised to solve a long-standing coding dilemma regarding diagnosis coding for post-hysterectomy Pap smears, resolution seems farther away than ever. The problem was Medicare's acceptance of only a cervical diagnosis code for low-risk screening Pap smears, even if the patient had a hysterectomy. The solution was Medicare's introduction of a noncervical code as a payable diagnosis for low-risk patients.

Now, after months of denials from various Medicare carriers for the new code for post-hysterectomy screening Pap smears, coders once again need to rethink the way they report these services.

By definition, a screening Pap smear is ordered in the absence of signs or symptoms of a disease. "If the patient presents with symptoms or a personal history that indicates a diagnostic purpose for the test, the Pap is not considered screening," explains Melanie Witt, RN, CPC, MA, an independent coding educator based in Fredericksburg, Va. In those cases, there are a host of diagnosis codes that indicate medical necessity for the test, according to Medicare.

However, in the absence of signs and symptoms, Medicare historically has indicated that only two diagnosis codes were acceptable to indicate medical necessity for a screening Pap smear. "Although ICD-9 provides other V codes that might accurately describe a patient's condition and the reason for the screening Pap, Medicare declared that only two of those codes would result in reimbursement when reported on item 24E of the HCFA-1500 claim form," Witt says. Those codes were ICD9 V76.2 (Special screening for malignant neoplasms, cervix) and V15.89 (Other specified personal history presenting hazards to health).

These two codes indicate whether the patient is at high or low risk for developing cervical cancer. Medicare established different frequency limitations for screening Pap smears based on the risk-level distinction. Low-risk patients are identified by V76.2 and are covered for a screening Pap smear once every two years. High-risk patients are identified by V15.89 and are covered once a year. Patients who have any of the following documented risk factors are considered high-risk: early onset of sexual activity, multiple sexual partners, history of sexually transmitted disease, fewer than three negative Pap smears within the previous seven years, and daughters of women who took DES (diethylstilbestrol) during pregnancy. Medicare adds that a woman whom the physician documents as being of childbearing age can be eligible for this screening benefit every year if she has or has had cervical or vaginal cancer. Any problem within the preceding three years that would put her at risk for developing cervical or vaginal cancer also qualifies her for a screening.

"The dilemma created by these Medicare coding requirements was that for low-risk patients who'd previously had a hysterectomy and therefore had no cervix, Medicare required that the screening be reported with V76.2, which effectively states that the patient has a cervix," Witt explains. "When the HCFA (now CMS) transmittal came out announcing a change to the Medicare Carriers Manual (MCM) that would include a noncervical-cervical code for low-risk patients who'd previously had a hysterectomy, coders thought their dilemma was solved."

The Medicare instruction, published in transmittal 1675 dated Aug. 31, 2000, added V76.49 (Special screening for malignant neoplasms, other sites) as a code accepted by Medicare for screening pelvic exams. It appeared by the wording to include screening Pap smears as well. MCM section 4603.2 C now states:

There are a number of appropriate diagnosis codes that can be listed in item 21 of the HCFA-1500 claim form for Pap smear or pelvic exam claims in addition to V76.2 or V76.49 (for low-risk patients) and V15.89 (for high-risk patients). However, one of the diagnosis codes in item 21 for low-risk beneficiaries must be V76.2 or V76.49, and this is the diagnosis code that must be pointed to in item 24E of the HCFA-1500. ... If Pap smear or pelvic examination claims do not point to one of these specific diagnoses in item 24E, the claim will be rejected in the common working file.

Although the change was effective Jan. 1, 2001, coders are still reporting denials for post-hysterectomy screening Pap smears reported with V76.49. "Many labs have been told by their carriers that V76.49 is only for use with the screening pelvic exams, not Pap smears," reports Elizabeth Sheppard, HT, (ASCP), manager of Anatomic Pathology at Wake Forest University Baptist Medical Center in Winston Salem, N.C. "That's why I recommend that coders contact their Medicare carrier for direction before implementing changes."

In fact, Witt's research shows only one carrier's local medical review policy (LMRP) stating acceptance of V76.49 for Pap lab codes. Generally, carriers are covering the screening pelvic exam code, G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination), when it is reported with V76.49, but denying the Pap smear collection code Q0091 (Screening Pap smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and the Pap laboratory codes when this diagnosis is used. Denials can occur for any of the following lab codes used to report screening Pap smears: