Primary Care Coding Alert

Pap smears are covered every two years for low-risk Medicare patients and annually for high-risk patients. But, family practice coders may face uncertainty when the physician has to perform the initial Pap smear or repeat the test. Understanding how to code the initial Pap will help coders when the repeat is performed.
 
"Sometimes a doctor receives abnormal results back from the lab and decides to repeat the test either to confirm the first result or to followup on the first result," says Melanie Witt, RN, CPC, MA, an independent coding consultant based in Fredericksburg, Va. "The second test is now diagnostic and not a screening like the first, and that changes the coding."

Medicare and private payers differ in their coverage of Pap smears as screening tests for high-risk patients. "High risk does not mean they had breast cancer, for example, because then it's not a screening, it's a diagnostic test," Witt says. A history of cancer usually prompts a diagnostic test. "There are specific criteria the patient must meet to qualify as high risk." A Medicare patient must have one of the following to be considered "high risk":

 

History of HIV (V08 or 042)
 

History of STDs (V13.8)
 

Five or more sexual partners in her lifetime (V69.2)
 

Onset of sexual activity before the age of 16 (V69.2)
 

Diethylstilbestrol (DES) exposure (760.76)
 

History of no Pap smears in the last seven years   (V15.89)
 

Absence of three consecutive negative Pap results     (795.0)
 

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.
 
 
"Medicare does not pay for an annual pap smear for any reason other than the ones stated above," Witt says. "If the patient has any other condition that the physician thinks makes her at high risk, he will either have to indicate that he is doing a diagnostic Pap smear or have to go along with the low-risk rules as stated by Medicare."
 
Tip: Practices may be uncomfortable asking Medicare patients questions relating to the above criteria. Put the questions on the history form the patient fills out before the visit. Above the questions include the phrase "if any of the following conditions are checked, Medicare covers the exam annually," or a similar statement. The physician is going to confirm the information with the patient and include it in the official documentation, as required by Medicare. 
 
The taking of the Pap smear specimen is considered part of the examination and should not normally be coded separately from the preventive service (99381-99397) or problem E/M visit (99201-99215). In some cases, private payers may reimburse for the handling of the specimen. If so, use the office visit (if the patient is in for a problem-oriented visit) or preventive code (if the patient is in for an annual exam) that is appropriate for the encounter, and also bill 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory). "Reimbursement will vary from payer to payer, but it tends to be a minor amount," Witt says.
 
Medicare, however, always reimburses for the collection of a specimen. "Medicare is the exception. It reimburses for the specimen collection every time the screening Pap smear interpretation is covered," Witt says.  When performing a Pap screening on a Medicare patient, bill Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) to reflect obtaining the specimen. In addition, code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and/or any separate and significant problem E/M service that was necessary at the time the Pap smear specimen was collected. If you bill the E/M service, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that it is separate from the Pap.
 
Coders should use the appropriate V code as the diagnosis code and link it to the Pap smear collection. For Medicare patients receiving their Pap smear every two years, use V76.2 (Special screening for malignant neoplasms; cervix, routine cervical Papanicolaou smear) with Q0091. For Medicare patients who qualify for the annual Pap screening, use V15.89 (Other specified personal history presenting hazards to health; other). In addition, report a secondary code for the condition that allows her to meet the criteria of an annual screening Pap smear and collection. (See list of criteria codes above.) 
 
Most private payers require one of the following codes alone or in combination on the examination, and the handling fee code 99000. Of the diagnoses listed below, Medicare only recognizes V76.2 with the Q0091.

 

V72.3 (Special investigations and examinations; gynecological examination) when the patient has a cervix

 

V76.2 (Special screening for malignant neoplasms; cervix) when the patient has a cervix

 

V76.47 (Special screening for malignant neoplasms; vagina) plus V45.77 (Other postsurgical states; acquired absence of organ; genital organs) when the patient's uterus and cervix have been removed for a nonmalignant condition

 

V67.01 (Follow-up examination; following surgery; follow-up vaginal pap smear)

 

V45.77 (Acquired absence of organ; genital organs) and V10.41-V10.44 (Personal history of malignant neoplasm; genital organs) when the uterus and cervix have been removed due to cancer.

When Pap smear results come back abnormal or display insufficient cells, the physician will perform another Pap. "Results can return abnormal for various reasons," says Joan Hubball, FNP, nurse practitioner at the Fernald Center in Waltham, Mass.  "Atypical squamous cells of undetermined significance (ASCUS), atypical glandular cells of undetermined significance (AGUS), or an inflammatory condition present at the time the smear was collected can affect the results." If the patient has an inflammation, such as vaginitis, that affects the results of the Pap smear, the FP will treat the problem and perform another Pap smear once it's resolved.
 
When the patient comes in for a second Pap smear, code the appropriate E/M office visit code. "You will probably be able to code a 99212 for this visit," Hubball says. "The patient will be coming in just to have the repeat Pap done, but because there is no code for taking the Pap you need to use the office visit code."
 
Some private payers may reimburse a handling fee for the repeat Pap smear specimen (99000). But for Medicare patients, the collection is considered part of the E/M service and should not be coded separately. Medicare will not reimburse for the Q code on the repeat Pap because it is a diagnostic test. "In this case, it's a problem E/M service, not a preventive screening," Witt says. "Now the specimen collection is definitely part of the E/M service, so Medicare will not reimburse for the collection."
 
Use 795.0 (Nonspecific abnormal Papanicolaou smear of cervix) as the diagnosis code if the physician repeats the Pap smear due to abnormal results. There are several scenarios that warrant coding 795.0.
 
Scenario #1, ASCUS: A 35-year-old female with multiple sexual partners presents for an annual exam. She has not had a Pap smear in four years. The Pap results return ASCUS, and the doctor asks her to come back in four months for a repeat Pap to follow any progress of the abnormal cells. When the patient returns, code the appropriate E/M office visit with 795.0 because the Pap is repeated due to abnormal cells.
 
Scenario #2, AGUS: A 45-year-old patient with no risk factors presents for a Pap. She has had regular Paps each year and is compliant with prescribed care. The results turn up AGUS. The physician calls the patient with the results and schedules a return Pap in four months. The second encounter would be coded with the proper E/M office visit and 795.0.
 
Scenario #3, Inflammation: A 25-year-old patient presents for her annual exam. During the pelvic exam, the FP notices that the patient has cervical discharge. In addition to the Pap smear, the physician does a wet-mount test and diagnoses the patient with trichomonas. The Pap smear reveals nonspecific inflammatory cells. After treating the infection, the FP takes a repeat Pap smear four months later. The second encounter would be coded with the an E/M office visit and 795.0.
 
Scenario #4, Inflammation: A 40-year-old patient comes in for her Pap smear. The FP notices slight inflammation but performs the Pap anyway and finds the patient has vaginitis. The lab results come back as abnormal due to the inflammation. When the patient returns for a Pap, code the office visit with 795.0.
 
If the patient needs another Pap smear because the sample was inadequate (i.e., the lab did not have enough cells in the specimen to interpret the results), use V76.2. For example, the physician may miss the cervical opening when taking the Pap smear because the patient is obese. The Pap result reads that no endocervical cells are present, meaning the physician only acquired outside cervical cell samples but none from the transition zone from the endometrium to the cervix where cancer often develops. The doctor would probably decide to perform a repeat Pap in such a case. For the second Pap, coders should use V76.2.
 
Some private payers will reimburse the repeat Pap smear, but others will not. If the insurance company won't pay, the practice or the lab can bill the patient for the Pap smear interpretation. If it's a Medicare patient, make sure she signs an advance beneficiary notice before the second Pap smear.