Primary Care Coding Alert

Although the Bethesda System (TBS) of reporting Pap smears is widely practiced, it is not accepted universally yet. Family physicians can avoid denials when reporting TBS by contacting payers in advance to explain the problems that may be encountered and to find out what they are willing to reimburse.

Laurie Castillo, MA, CPC, of Physician Coding and Compliance Consulting in Manassas, Va., explains that TBS was formulated by a group of leading cytopathologists and gynecologists in 1988 at a conference in Bethesda, Md. The purpose of Bethesda, says Castillo, was to eliminate reporting of Pap smears by classes. The recommendations that were made for a uniform diagnostic terminology for cervical/vaginal cytology were supported, as well as sponsored, by the National Cancer Institute, which then led to the new classification. Castillo explains that essentially TBS contains more descriptive terminology instead of Class 1 or normal, Class 2, Class 3, Class 4 or Class 5. Now you see more descriptive diagnoses such as low-grade squamous intraepithelial lesion (LSIL) encompassing HPV mild dysplasia/CIN 1 instead of Class 2 or Class 3, says Castillo.

The three formative components of the Bethesda System are:

1. a statement on adequacy of the specimen for evaluation;

2. a general categorization that may be used to assist with clerical triage (optional); and

3. the descriptive diagnosis.

Evaluation of the integrity of the specimen, and the more descriptive diagnosis are the areas where TBS most differs from the standard or non-Bethesda system of reporting. In particular, the more detailed diagnostic reporting results in more work being done in the labwhich translates into a higher code and, presumably, higher reimbursement.

The Bethesda System is now a widely practiced, though not universally accepted, method of screening Pap smears. Proponents of TBS insist that it establishes a much more detailed and less ambiguous framework for reporting the test results. It is regarded as particularly helpful in the early detection of cancerous and pre-cancerous cells in the cervix. As Melanie Witt, RN, CPC, MA, and former program manager of the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG), puts it, The Bethesda System of reading a Pap test is one of the standards, and some feel that it is a vast improvement over the older classification system. For those who support Bethesda, it is the only game in town.

So why are some payers still balking at the idea of reimbursing for the more detailed screening? In one case, the practice submitted 88166 (cytopathology, slides, cervical or vaginal [the Bethesda System]; with manual screening and computer-assisted rescreening under physician supervision). More than one payer denied the claim but said they would accept it if it was recoded to 88150 (cytopathology, slides, cervical or vaginal; manual screening under physician supervision [non-Bethesda System]). The payers argued that TBS was not a necessary step for an average patient for whom there was no suspicion of precancerous or cancerous cells, or any other signs of abnormality.

I think what the payer was really objecting to, says Witt, was code 88166, which includes rescreening. In an asymptomatic patient, the computer-assisted rescreening probably was deemed superfluous. The request from the payer should have been to recode to 88164 (cytopathology, slides, cervical or vaginal [the Bethesda System]; manual screening under physician supervision), says Witt.

If the physician involved believes that the rescreening
is a necessary part of the reporting process for this or any patient, then Witt advises that the best approach is to write a detailed letter to the insurer that clearly presents the argument for the additional screening. This standard letter, applicable to any insurer who denies the code, should include the difference between the two processes and the advantages of the Bethesda and non-Bethesda system. Case histories in which the computer-assisted rescreening has detected abnormalities overlooked in the manual screening (particularly those involving an asymptomatic patient) will undoubtedly bolster the case for the more thorough method and the higher code.

While the rescreening may be more than is typically required for a normally healthy patient with no previous problems and no family history to worry about, that decision rests with the physician, not the payer, says Witt. The choice between a manual screening interpretation using the classification system preferred by the physician should be a medical decision, not a financial decision.