Pathology/Lab Coding Alert

Capture annual screening opportunity with this V code.

If your labs physician clients order screening Pap smears every year, you might be missing pay for many tests. Make sure you know when your payer will cover the test and how to report it-- to avoid Pap test denials.

Know Risk Level

Although screening Paps are for patients without signs or symptoms of disease, Medicare and many other payers further distinguish these patients based on their risk of acquiring cervical cancer.

Low-risk patients are women of child-bearing age or post-menopausal women who do not exhibit any risk factors associated with the high-risk group.

Do this: To classify a patient as high-risk, use V15.89 (Other specified personal history presenting hazards to health; other).

The ordering physician should supply a secondary diagnosis to explain why the patient is high-risk. The diagnoses include:

" history of HIV (V08 or 042)

" history of sexually transmitted diseases (V13.8)

" five or more sexual partners (V69.2)

" began sexual activity before 16 years of age (V69.2)

" diethylstilbestrol (DES) exposure (760.76)

" seven years without a Pap smear (V15.89)

" absence of three consecutive negative Pap results (795.09)

" absence of any Pap tests in previous seven years

" any gynecological problem (such as cervical or vaginal cancer or genitourinary system problem) in the last three years if the patient is of childbearing age.

Note that Medicare does not recognize breast cancer as a high risk factor, according to MelanieWitt, RN, CPC, COBGC, MA, a coding expert based in Guadalupita, N.M.

Adhere to Frequency Rules

Best-practices Pap frequency guidelines and payer frequency coverage rules may not see eye-to-eye -- and you need to know the difference.

The American College of Obstetricians and Gynecologists (ACOG) recommends that women who have reached 18 years of age or have been sexually active should undergo an annual Pap test and pelvic examination. Following at least three annual cytologic exams with normal findings, the physician may choose to screen less frequently, according to ACOG.

For women 65 and older who have had at least three documented normal Pap smears and no risk factors, ACOG says they no longer require screening, Witt says.

Flag Medicare difference: If youre dealing with Medicare or a payer that follows Medicare guidelines, you can expect frequency coverage rules that vary fromACOG.

For Medicare patients at low risk, you can report a Pap smear only once every two years. If the patient is high-risk, you can bill a Pap smear annually.

These coverage rules apply for cervical smears or vaginal smears following hysterectomy for non-malignant reasons. The frequency rules also apply regardless of the patients age, according to Witt.