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 [...]