Primary Care Coding Alert

Question: If a patient comes in for a Pap smear, can we charge for an office visit along with the test or just for the Pap smear? And, what are the appropriate codes for a Pap smear?

Latrelle Ward
Office of Antonio L. Ong, MD, Hinesville, Ga.

Answer: You may charge for an office visit, 99212-99215 (office or other outpatient visit for the evaluation and management of an established patient) says Jean Stoner, CPC, manager, coding operations for CodeRyte, a coding software company in Bethesda, Md.

Be sure to adequately document the office visit as part of the Pap collection, she says. There is no other way to bill for the procedure because there is no separate code for a Pap smear.

If the office also analyzes and interprets the Pap smear, use the appropriate lab codes (88141-88155, 88164-88167) that describe cervical or vaginal screening by various methods and report physician interpretation services, and attach the diagnostic code V76.2 (special screening for malignant neoplasms; cervix, routine cervical Papanicolaou smear). Stoner warns not to bill the lab codes if your office only collected the Pap smear and sent them to a lab for analysis.

If an established patient comes in for a Pap smear as part of a head-to-toe preventive care examination, code 99395 (periodic preventive medicine reevaluation and management of an individual including comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, established patient, 18-39 years); 99396 (40-64 years) or 99397 (65 years and older). If the patient is new, use the similar corresponding codes 99385-99387. Again the appropriate lab codes apply if your office analyzed and interpreted the Pap smear results, explains Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

A patient has had a previous abnormal Pap smear so she comes in every four months just for a Pap and no other procedure. Code 99212-99215 and 795.0 (nonspecific abnormal Papanicolaou smear of cervix), Callaway-Stradley says.

If its a Medicare patient, the situation is different. As a preventive examination, head-to-toe, code 99397 (periodic preventive medicine reevaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of appropriate laboratory/diagnostic procedures, established patient; 65 years and older), plus G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) with a -GA modifier (waiver of liability statement on file) since Medicare will only cover the Pap smear once every three years for most Medicare patients, explains Andrea Lamb, CPC, billing clerk at Upshor Medical Management Services, an 11-doctor managed group practice in Buckhannon, W.Va. You should use the modifier -GA just in case it is difficult to determine where the patient is in the three-year cycle, she says.

Medicare will cover a screening pelvic exam annually if the beneficiary falls into one of the following categories:

1) of childbearing age and has had an exam indicating the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years, or

2) considered to be a high risk for vaginal cancer as evidence by prenatal exposure to diethylstilbestrol or for cervical cancer as evidenced by any of the following early onset of sexual activity (under 16 years of age), multiple sexual partners (five or more in a lifetime), history of sexually transmitted disease (including HIV) and an absence of three negative Pap smears or the complete absence of Pap smears within the previous seven years.

When billing for a Medicare patient and using G0101, you also must document seven of the following bullet points prescribed by Medicare, Callaway-Stradley says. They are:

- inspection and palpation of breasts for masses or
lumps, tenderness, symmetry or nipple discharge;

- digital rectal examination including sphincter tone,
presence of hemorrhoids and rectal masses; and

- pelvic examination (with or without specimen
collection for smears and cultures) including:

- external genitalia;

- urethral meatus;

- urethra;

- bladder;

- vagina;

- cervix;

- uterus; and

- anus and perineum.

In addition, code Q0091 (screening Papanicolaou smear: obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and V76.2. Callaway-Stradley says it is unlikely that a FP will do the lab work of a Medicare patient since the lab bills Medicare directly, thus the 88141-88155, 88164-88167 codes are unnecessary.

If the Medicare patient comes in just for a Pap smear, due to a problem rather than as a preventive measure, Callaway-Stradley says to code Q0091 with 795.0.

Finally, Callaway-Stradley offers a formula to keep in mind for Medicare patients: Charge the patient $100 for the head-to-toe, preventive care examination. Medicare allows $28 for the breast and pelvic exam and $26 for Q0091, or a total of $54. You should collect $56.80 ($100 - $54 = $46, plus 20 percent of $54, or $10.80) from the patient. Medicare pays 80 percent of the $54 or $43.20.