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Primary Care Coding Alert

V72.31 Joins Medicare's List of Low-Risk Patient ICD-9 Codes

Published on Thu Jul 07, 2005

Reserve V72.31 for Pap during a gynecological exam

You'll no longer have to use different Pap smear diagnosis codes on well-woman checks, thanks to Medicare's new addition of V72.31.

Starting July 1, 2005, you may use V72.31 (Routine gynecological examination) with Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory).

On claims for low-risk Medicare patients, Medicare carriers will now only accept V76.2 (Special screening for malignant neoplasms, cervix), which includes routine cervical Pap smear.

Report All Well-Woman Paps With v72.31

Code V72.31 shouldn't be entirely new to you. Most commercial payers have always accepted this diagnosis code when a family physician performs a full gynecological examination.
 
In other words: You may use V72.31 for a routine gynecological examination with or without a Pap smear, regardless of insurer. "If Medicare wants us to use V72.31, then that's fine by me - as long as they get it right," says Christine Dubois, CPC, the coding coordinator and compliance office for Western Mass Physician Associates in Holyoke, Mass.

This ICD-9 code joins the other applicable diagnosis codes that Medicare will accept for low-risk patients:
 

  • V76.2 - Special screening for malignant neoplasms, cervix
  • V76.47 - Special screening for malignant neoplasms, vagina
     
  • V76.49 - Special screening for malignant neoplasms, other sites (Note: You should use this diagnosis for women without a cervix.)

    New way: You will be able to use V72.31 as another Medicare option provided the FP performs a full gynecological exam.

    Re-Educate Staff on Single Diagnosis Code

    Although Medicare's new addition will initially require additional training, you will eventually enjoy streamlined ICD-9 coding.

    On one hand, you may have a hard time re-educating your staff that they have another code out there to use. Coding clinics emphasize reporting V76.2, and now experts will have to change their advice.

    But on the other hand, you now have the freedom to follow the exact rules commercial payers follow for a full gynecological exam. "We feel that V72.31 will be easier to use because the office staff are used to using that code for regular Paps" on non-Medicare claims, says Cathie Hays, RHIT, a coding and billing specialist at Sparta Community Hospital, Quality Healthcare Clinics in Sparta, Ill.

    Stick With G0101 and Q0091

    Medicare's change in the well-woman-check diagnosis code does not affect the procedure codes you use. You should still report a: 

  • breast and pelvic exam with G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination)
     
  • Pap smear as Q0091
     
  • preventive medicine service (such as 99387, Initial comprehensive preventive medicine evaluation and management of an individual ...; 99397, Periodic comprehensive preventive medicine re-evaluation and management of an individual ...) (Bill the patient, not your Medicare carrier, for this portion.)

    Remember: You can also report a new or established patient E/M code (99201-99215 Office or other outpatient visit for the evaluation and management of a new or established patient ...), but the FP must document a separate and distinct E/M service and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99201-99215.
     
    Use -76 for Repeat Pap

    When a Medicare patient is low-risk, the carrier will cover the associated well-woman-check services - the screening Pap smear and breast/pelvic exam - once every 24 months.

    Problem: If the lab informs you the specimen is inadequate for determination, you have to report Q0091 a second time during the noncovered period. "Starting July 1, 2005, Medicare will allow modifier -76 to override the frequency edit," says Pamela J. Biffle, CPC, CCS-P, ACS-DE, approved PMCC instructor, product development director of Custom Coding Books in Bellevue, Wash.
     
    Modifier -76 (Repeat procedure by same physician) tells the carrier that the physician had to repeat the procedure.

    The diagnosis will further explain the repeat Pap. You should report the resubmission Pap smear (Q0091) with V76.2 (Special screening for malignant neoplasms, cervix), V76.47 (Special screening for malignant neoplasms, vagina) or V76.49 (Special screening for malignant neoplasms, other sites). You would not use V72.31 (Routine gynecological exam), because the FP isn't performing a full gynecological exam.

    You should also link 795.08 (Unsatisfactory smear) to Q0091, which will help explain why the patient required the repeat service.

    Say Goodbye to Incorrect Q0091 Payments

    In addition to accepting V72.31, Medicare will also implement new frequency edits on Q0091. Even though you know Medicare covers a screening Pap every 24 months, carriers have been incorrectly paying Q0091 on the off years, Hays says. "We are therefore having to refund Medicare."

    Relief in site: Starting July 1, 2005, a system edit for Q0091 will take effect "so that claims will pay appropriately," states the CMS in Transmittal 440.

    Editor's note: You can read the transmittal in its entirety at URL www.cms.hhs.gov/manuals/pm_trans/R440CP.pdf. Medicare has also issued a Medlearn Matters provider education article on the changes available from www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3659.pdf.

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