Internal Medicine Coding Alert

Published on Thu Jan 28, 2010 PDF

Know when reporting a Pap smear can equal payment -- or denial.

If you don't know a patient's risk level, you won't be able to determine how often Medicare will cover a Pap smear.

Guideline: Medicare provides coverage of a screening Pap test for all female beneficiaries when a doctor of medicine or osteopathy or other authorized practitioner orders and collects the test under one of the following conditions, according the to the Medicare Preventive Services Cancer Screening Manual:

• There is evidence (on the basis of her medical history or other findings) that the woman is of childbearing age and has had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding three years; and at least 11 months have passed following the month that the last covered Pap test was performed.

• There is evidence that the woman is in one of the high-risk categories for developing cervical or vaginal cancer and at least 11 months have passed following the month that the last covered screening Pap test was performed. High risk factors for cervical and vaginal cancer include:

-- early onset of sexual activity (less than 16 years of age),

-- multiple sexual partners (five or more in a lifetime),

-- history of a sexually transmitted disease [including human papillomavirus (HPV) and/or human immunodeficiency virus (HIV)],

-- fewer than three negative Pap tests within the previous seven years, and

-- DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy.

Medicare provides coverage of a screening Pap test for all other female beneficiaries (low risk) every two years (that is, at least 23 months have passed following the month in which the last covered screening Pap test was performed).

Source: www.cms.hhs.gov/MLNProducts/downloads/cancer_screening.pdf.