Pathology/Lab Coding Alert

Question: How should we use the new ICD-9 codes for -satisfactory smear but lacking transformation zone?- Should we report the appropriate cervical or anal code in addition to normal and abnormal test results?

Arizona Subscriber

Answer: You should only use the new codes you-re asking about -- 795.07 (Satisfactory cervical smear but lacking transformation zone) or 796.77 (Satisfactory anal smear but lacking transformation zone) -- when the smear results are abnormal.

Here's how: List the abnormal finding first, such as 795.02 (Papanicolaou smear of cervix with a typical squamous cells cannot exclude high grade squamous intraepithelial lesion [ASC-H]). By listing 795.07 second, you alert the physician that the transformation zone was not present in the sample. The code also indicates that you had enough cells to make a diagnosis (you had a satisfactory smear). Code 795.07 provides information that allows the physician to decide if he or she wants to order a repeat Pap test.

Background: The transformation zone in the cervix or anus is the area where mucosa turns from squamous to columnar cells. Cytologic changes indicative of cancer often occur in this region, which is why Pap smears generally sample from the transformation zone.

The cervical transformation zone, however, changes position in response to a woman's hormonal changes. 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.

The vagina doesn't have a transformation zone, which is why CPT 2009 didn't add a code for vaginal smears similar to the new codes for cervix (795.07) and anus (796.77).