Pathology/Lab Coding Alert

Question: If we perform a screening Pap smear and high risk HPV test for a Medicare beneficiary, how should we bill?

Codify Subscriber

Answer: You should bill the screening Pap plus high risk HPV screening to Medicare using G0476 (Infectious agent detection by nucleic acid [DNA or RNA]; human papillomavirus [HPV], high-risk types [e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68] for cervical cancer screening, must be performed in addition to pap test).

Caveat: Medicare covers this screening only once every five years for asymptomatic patients aged 30 to 65 years. You must perform both the Pap and the HPV tests to use his code. Also, the ordering physician must demonstrate medical necessity for the test using an appropriate ICD- 10 “Z” code combination such as Z11.51 (Encounter for screening for human papillomavirus [HPV]) and Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings); or Z11.51 and Z01.419 (… without abnormal findings).

Medicare only recently began covering the two tests together as a screening test. Prior to the change, you had to bill the Pap smear using a code such as G0123 (Screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin-layer preparation, screening by cytotechnologist under physician supervision) and then report abnormal findings such as R87.610 (Atypical squamous cells of undetermined significance on cytologic smear of cervix [ASC-US]) to demonstrate medical necessity for the HPV test, such as 87624 (Infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV], high-risk types [e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68]). Some payers may have also required you to report Z11.51 so that the screening would not be subject to the patient’s deductible and copay.