Primary Care Coding Alert

Risk level key to code choice, test frequency.

When both the US Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) recommend Pap tests for all women between 21 and 65 years old to prevent cervical cancer, you know that the procedure is one of the most important ways your primary care practice can ensure the health of your female patients (Sources: https://www.cdc.gov/cancer/cervical/basic_info/screening.htm and https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening).

But even though the collection of a Pap specimen is relatively easy, coding the procedure and its related ICD-10 code isn't quite as straightforward. Medicare and private payer guidelines are very specific as to what codes you can, and cannot, use, and knowing the functions of the different CPT^® and HCPCS codes is equally important for accurate documentation.

So, read on to learn the best way to code this critical service.

Know Who to Screen and When

According to CMS guidelines, Medicare Part B will cover screening Pap smears every two years for women of childbearing age (premenopausal), and more frequently (i.e. annually) for women deemed to be in the high-risk category for cervical and vaginal cancer. The guidelines define high-risk as:

• A history of early sexual activity (i.e. activity before the age of 16).
• A history of multiple partners (i.e. five or more in a lifetime).
• A history of sexually transmitted disease (including HIV).
• Women who were born to mothers who took DES (diethylstilbestrol) during pregnancy.
• Women who have had fewer than three negative or no Pap tests within the previous seven years.

A woman of childbearing age who has had a screening pelvic examination or Pap test during any of the preceding three years that indicated the presence of cervical or vaginal cancer or other abnormality is also eligible for an annual screening Pap test (Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Screening-papPelvic-Examinations.pdf).

Know Which Procedure Code Applies ...

"The only code that is reported for the collection of a screening Pap smear specimen," according to Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico "is Q0091 [Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory]."

However, Witt adds a note of caution regarding the code. "This Q code was created by Medicare for their billing purposes," Witt explains, adding that "very few private insurers would recognize it." In addition, Witt notes, "the collection of a Pap smear specimen when done for diagnostic purposes rather than screening should be included in the appropriate evaluation and management [E/M] code billed."

Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas, agrees and notes that "it is inappropriate to bill for a Pap smear during a problem-focused visit where the pap smear would be part of the workup. For example, Charles goes on, "if a patient is seen for vaginal discharge and a Pap smear is performed during the same encounter, only the E/M should be reported."

However, Charles advises, "if the Pap smear is done during a preventive visit, then you should code the appropriate preventive medicine CPT^® code from 99381–99397 [... comprehensive preventive medicine evaluation and management of an individual ...] for a commercial carrier or G0101 [Cervical or vaginal cancer screening; pelvic and clinical breast examination] with Q0091 for Medicare."

... Which Ones Don't ...

None of the other HCPCS codes for Pap smears - and there are plenty of them - will typically apply in the primary care setting. G0123, G0143-G0148 (Screening cytopathology ...), and P3000 (Screening Papanicolaou ...) Witt notes, "are laboratory codes, done by technicians under physician supervision" while G0124, G0141, and P3001 (... requiring interpretation by physician) are interpretation codes that are most often billed by a pathologist.

Similarly, CPT^® codes 88141-+88177 (Cytopathology ...) are screening lab codes using different reporting methods and, in some cases, including the interpretation as well. All represent the actual performance of the Pap test, which most laboratories in the primary care setting are not equipped to perform. These codes should not be reported simply for collecting the specimen. As noted, Q0091 is billed by the physician who took the smear and sent it to the lab, when recognized by the payer.

... and Which Dx Code to Apply

Medicare also requires that you report Q0091 with a related ICD-10 code depending on whether the patient is low- or high-risk. At present, Witt notes, "Medicare will accept the following codes for the collection of a low-risk screening Pap every 2 years."

Coding caution: Both Witt and Charles note that linking other diagnosis codes, additional codes, or the incorrect code to Q0091 will result in a Medicare denial. Additionally, Charles' audits have revealed that "the code must be linked by the actual provider documenting the record, not by a nurse, scribe, or ancillary staff member that entered it on behalf of the physician."

Finally, Witt suggests practices should "make sure the appropriate time has elapsed between screening Pap smears. In those cases where it will not be covered every year," Witt advises, "the patient must sign an advance beneficiary notice [ABN] before your practitioner obtains the specimen." More, Witt concludes, the "ABN must be specific to the service on this date of service that might not be covered, and not be a generic ABN that covers any circumstance that may or may not apply."