Primary Care Coding Alert

When tests, exams or procedures need to be repeated, family practice coders are often concerned that claims may be summarily rejected. Most carriers use frequency edits to alert physicians that they will allow certain types of services only at specified intervals.

Such is the case with Pap smears. Medicare, for instance, reimburses for screening Pap smears only once every three years unless the patient is categorized as high risk or has a personal history of an abnormality. If that is the case, annual Pap smears are then allowed.

But many coders wonder how to report Pap smears that are done even more frequently, specifically when a screening study exhibits abnormal results and is repeated several times within a few months. The answer is straightforward, according to Melanie Witt, RN, CPC, MA, an independent consultant specializing in coding and documentation education based in Fredericksburg, Va., and former program manager for the department of coding nomenclature at the American College of Obstetrics and Gynecology (ACOG).

There is a simple rule of thumb, she explains. Coders should remember to code only what they know at the time of each visit when the Pap smear is collected.

Step 1: Coding the Original Screening Pap Smear

Coding the initial Pap smear correctly depends on a number of factors. If the specimen is collected during an annual preventive care visit, coders should choose the appropriate code from the 99395-99397 (established patient) or 99385-99387 (new patient) series. Coders have three diagnostic linkage possibilities to choose from:

V72.3 (gynecological examination) when the patient has a cervix;

V72.3 plus V76.47 (special screening for malignant neoplasms; vagina) plus V45.77 (acquired absence of uterus) when the patients uterus and cervix have been removed for a non-malignant condition; or

V67.01 (follow-up vaginal pap smear) plus V45.77 plus V10.14-V10.44 (personal history of malignant neoplasm, genital organs) when the uterus and cervix have been removed due to cancer.

If the screening Pap smear is collected during an office or outpatient visit for a specific problem, coders would select from 99212-99215 (established patient) or 99201-99205 (new patient). In either instance, V76.2 (special screening for malignant neoplasms; cervix, routine Papanicolaou smear) or V76.47 would be assigned in addition to the problem encountered unless the purpose of the visit was for follow-up to cancer. In that case, the correct additional code would be V67.01.

Some practices may also have qualified under the Clinical Laboratories Improvement Act (CLIA) regulations to perform the Pap smear interpretation. In this case, they would also report the appropriate lab codes (88141-88155, 88164-88167) linked to a diagnosis that supports why the test was ordered.

Code Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) would also be reported if the patient is a Medicare beneficiary and the Pap specimen is collected at the time of a:

Medicare-covered screening examination (G0101, cervical or vaginal cancer screening; pelvic and clinical breast exam);

Noncovered preventive service (99387 or 99397); or

Problem visit (modifier -25 would be added to the problem evaluation and management (E/M) service billed to show that the E/M service was significant and separately identifiable from the specimen collection).

Medicare requires a diagnosis code of V76.2 or V76.49 for the patient who does not have a uterus or cervix when the Pap collection is billed every third year. However, it requires V15.89 (other specified personal history presenting hazards to health) when the screening Pap interpretation is allowed every year for patients who are in the Medicare-defined high-risk category.

Coders should note that V76.49 is the only code that has been authorized for use when the patients uterus and cervix have been removed surgically. It is an alternative to V76.2 to justify the once-every-three-years Pap interpretation and specimen collection. The correct ICD-9 code is V76.47, but Medicare does not now accept this code.

Step 2: Coding the First Repeated Pap Smear

You would be repeating the Pap smear because the screening study came back with abnormal results. Therefore, you would assign the appropriate diagnosis code that best describes the condition, explains Randy Thomson, CPC, coding specialist at HMI, a company specializing in Part A and Part B billing, based in Nashville, Tenn. Examples include 622.1 (dysplasia of cervix) or 795.0 (nonspecific abnormal Papanicolaou smear of cervix). The collection of the specimen would be reported with the appropriate established patient office/outpatient evaluation and management code, 99212-99215.

The Pap smear is now a diagnostic study, however, not a screening exam. Consequently, Q0091 would not be assigned for Medicare patients because the collection is now part of the E/M service being billed for the abnormal Pap smear result.

Step 3: Coding the Second Repeat Pap Smear

Four months after the repeat Pap smear, the patient returns for another follow-up and, again, the service would be coded to reflect what the physician knows at that time, Witt says.

If the second Pap smear also shows an abnormality, the coding would be the same as the first follow-up.

However, if the first follow-up Pap came back with normal results, coders would report the personal history code V13.2 (personal history of other diseases; other genital system and obstetric disorders) to describe the previous abnormal Pap smear due to dysplasia or other nonmalignant conditions, she says. But because this is still a screening test since the last one was normal, V76.2 or V76.47 should once again be assigned as well.

I advise coders to list the personal history code first on the claim, because this will quickly alert carriers that there is a good reason for the Pap smear to be repeated, Witt says. Its a flag that will let them know that this is a diagnostic, not a screening, service.

Thompson adds that some carriers may request a copy of the laboratory reports to document the need for the repeated studies.