Quick Coding for Women’s Preventive Services
Women’s screening codes and coverage may vary depending on risk factors.
Coding for women’s preventive services requires a firm understanding of not only the procedures, but also of the related codes and coverage requirements.
Cervical Cancer Screening
Several CPT® code families describe Pap tests, depending on how tissue samples are prepared for examination.
During a conventional Pap smear (CPT® 88150-88154 Cytopathology, slides, cervical or vaginal), the collected sample is smeared directly onto a microscope slide for examination. Final code selection depends on how the results are screened (i.e., manually with physician supervision, manually with computer-assisted rescreening under physician supervision, or manual screening and rescreening under physician supervision).
The Bethesda method (CPT® 88164-88167 Cytopathology, slides, cervical or vaginal (the Bethesda System)) evaluates specimen adequacy and provides specific categories for abnormal findings. It has been updated twice since its introduction in 1988. As with a conventional Pap smear, final code selection depends on the method of screening and, when applicable, the method of rescreening.
For the liquid preservative method, such as ThinPrep® (CPT® 88174-88175 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation), the collected sample is preserved in liquid rather than smeared directly onto a slide. This helps to prevent drying and clumping of cells and improves diagnosis accuracy. Final code selection depends on whether the screening is fully automated, or automated with manual rescreening under physician supervision.
The most common tests combine liquid preservation with Bethesda methodology (CPT® 88142-88143 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation). The sample is manually screened under physician supervision. Final code selection depends on whether there is also rescreening under physician supervision.
Breast Cancer Screening
There is no separate code to report a clinical breast exam; instead, the service would count as part of any preventive or E/M service provided.
Code 77057 Screening mammography, bilateral (2-view film study of each breast) describes a bilateral screening mammogram. Apply +77052 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure) if a computer is used to review the mammography results.
Ovarian Cancer Screening
Report a limited ultrasound assessment for ovarian screening using 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles).
Per the American Urological Society, elements of a complete pelvic ultrasound (76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete) go beyond examination of the ovaries to include medically necessary examination with a description and measurement of the uterus and adnexal structures, endometrium, bladder, and of pelvic pathology (e.g., ovarian cysts, uterine leiomyomata, free pelvic fluid). Do not apply 76856 for a limited ovarian screening.
You may report the blood test CA 125 using 86304 Immunoassay for tumor antigen, quantitative; CA 125.
There are several screening tests for osteoporosis. The most common is dual energy X-ray absorptiometry (DEXA or DXA), reported with 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) or 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel).
Tip: For more information on DEXA scans and other bone density testing methods, see “Strengthen Your Bone Density Test Coding,” November 2013 Cutting Edge (https://www.aapc.com/blog/strengthen-your-bone-density-test-coding/).
Medicare and CPT® Requirements Differ
Medicare coverage for women’s screening exams may vary, depending on whether the Medicare beneficiary qualifies as high risk. For example, Medicare Part B covers a screening Pap test for all asymptomatic female beneficiaries every 24 months. Medicare will cover Pap screening annually for beneficiaries of childbearing age who have had an abnormal Pap test within the past three years, or beneficiaries at high risk for cervical or vaginal cancer. High-risk categories include:
- Early onset of sexual activity (under 16 years of age);
- Multiple sexual partners (five or more in a lifetime);
- History of a sexually transmitted infection, including human immunodeficiency virus (HIV) infection;
- Fewer than three negative Pap tests or no Pap tests within the previous seven years; and
- Diethylstilbestrol (DES)-exposed daughters of women who took DES.
CMS designates nearly a dozen HCPCS Level II codes to describe various screening Pap tests, including physician supervision and laboratory specimens.
Medicare covers a screening pelvic examination (G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination) every two years for most female beneficiaries. If the patient meets Medicare’s criteria for high risk (similar to those for Pap smear), the examination is reimbursed every year.
Medicare Part B covers screening mammogram annually for beneficiaries aged 40 and older. CMS accepts the standard CPT® codes for screening mammography, but also designates HCPCS Level II code G0202 Screening mammography, producing direct digital image, bilateral, all views for bilateral screenings producing direct 2-D digital images.
For bone density screening, Medicare accepts CPT® DXA codes, as well as G0130 Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel), when applicable. Screenings are covered every 24 months for beneficiaries who meet program requirements.
Access the Medicare Learning Network booklet on Screening Pap Smears at:
To learn more about screening pelvic exams, see: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Screening-Pelvic-Examinations.pdf.
Complete guidance on mammogram screening may be found in the Medicare Claims Processing Manual, chapter 18, section 20: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf.
For more information on bone density screening, visit:
Kerin Draak, MS, RN, WHNP-BC, CPC, CEMC, COBGC, has been in the healthcare field for over 24 years. She is the director of ICD-10 implementation and the Clinical Documentation Integrity Program for the Hospital Sisters Health System. Draak has served on AAPC’s National Advisory Board as a member (2009-2011) and an officer (2011-2013). She spoke at AAPC’s national conferences in 2008 and 2009, and has authored several coding articles. She is a member of the Green Bay, Wis., local chapter.
John Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Asheville-Hendersonville, N.C., local chapter.
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