You Be the Coder:
Pap Smear
Published on Thu Mar 01, 2001
Question: The initial screening for a Pap smear was within normal limits. But during quality assurance (QA) review, atypical cells are identified and an addendum report stating this is issued. Can the pathologist bill CPT 88141 for the addendum report?
Maine Subscriber
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Answer: This question falls into an ethical dilemma and no hard and fast answer is available. Code 88141 (cytopathology, cervical or vaginal [any reporting system]; requiring interpretation by physician [list separately in addition to code for technical service]) should only be ordered when requiring interpretation by physician. The key word in this code is requiring. In this case, the cytotechnologists initial screening did not require physician interpretation. Rather, the review of the slide was part of the labs QA, not at the cytologists request based on an abnormal screening. That would make it a non-billable test. These nonbillable tests are rare. It is quite well documented that any billing associated with QA is not acceptable, as QA is considered part of the service provided with the procedure.
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