Advanced Search

Ob-Gyn Coding Alert

Are You Using Cytopathology Codes for Reporting Pap Smears in the Office?

Published on Tue Mar 30, 2004

There are better choices that won't get you in trouble

If you're tempted to report 88141 or another cytopathology smear code when your ob-gyn performs a Pap smear, don't give in. They're usually part of another service.
 
"Generally, Pap smears are included in the E/M service," says Brenda Dombkowski, CPC, a coding specialist at Obstetric-Gynecology & Infertility Group in Cheshire, Conn. You would report +88141 (Cytopathology, cervical or vaginal [any reporting system]; requiring interpretation by physician [list separately in addition to code for technical service]) or other cytopathology smear codes in this group for interpreting the Pap results, which a pathologist usually performs, she adds.

Pap smears are one of the most commonly done procedures in an ob-gyn office. In fact, there's a strong connection between early cancer detection and Pap smears, so testing patients is a high priority for ob-gyn practices. Nonetheless, coding for this service remains a confusing issue for many because they're not sure if they should bill it separately.

Beware: In particular, watch out for encounter forms that list the cytopathology codes for the physician to check off. This often leads the doctor to believe that carriers should separately pay him or her for performing the test. "The doctor taking the Pap smear is usually not the provider screening the smear," Dombkowski says. If this is the case in your practice, do not bill a lab charge (for example, 88141), she points out.

Mind You G's and Q's for Medicare

When a Medicare patient presents to your office for a Pap smear and pelvic and breast exam, you should report HCPCS codes Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination).

Don't forget: Medicare will pay for one Pap test every two years for low-risk patients and annually for high-risk patients. And you can report both Q0091 and G0101 with an E/M service as long as you can separately identify the service. If this is the case, you would append the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

There are specific criteria the patient must meet to be considered high-risk. In fact, for a Medicare patient who is presenting for her annual Pap smear and meets the criteria for high risk, you should report V15.89 (Other specified personal history presenting hazards to health; other) in addition to a secondary code that details why she is considered high-risk. The secondary code must match one of the following diagnoses for the patient to be considered high-risk under Medicare:

  •  History of HIV (V08 or 042)
  •  History of sexually transmitted diseases (V13.8)
  •  Five or more sexual partners in her lifetime (V69.2)
  •  Onset of sexual activity before 16 years of age (V69.2)
  •  Diethylstilbestrol (DES) exposure (760.76)
  •  History of no Pap smears in the last seven years (V15.89)
  •  Absence of three consecutive negative Pap results (795.0x)
  •  Any gynecological problem (such as cervical or vaginal cancer or genitourinary system problem) in the last three years if the patient is of childbearing age.

    Medicare does not pay for an annual Pap smear for any reason other than those listed. If the patient has any other condition that the ob-gyn thinks makes her high-risk, he will either have to indicate that he is doing a diagnostic Pap smear or have to follow the low-risk rules as stated by Medicare -- that is, one Pap smear every two years.

    "Be sure that your Medicare claims are appended with the appropriate modifiers and that you have advance beneficiary notices (ABNs) signed as necessary," says Peggy Stilley, CPC, office manager for Women's Healthcare Specialists, an Oklahoma University-based private ob-gyn practice in Tulsa. "If you have not seen the patient before and you have no record of previous Paps, you will be unaware if this is the payable year."

    If you are providing a Pap smear for a low-risk patient, you should report V76.2 (Special screening for malignant neoplasms; cervix) as the diagnosis code.

    Well-Woman Includes Pap Smear

    Physicians almost always include a Pap smear as part of the well-woman examination for a non-Medicare patient. Even though the woman hasn't reported a problem, the ob-gyn performs the test as part of a comprehensive preventive medicine service. This includes obtaining the sample and making the slide.

    What you should do: In this case, you should report one of the preventive medicine codes (99384-99387 for new patients, and 99394-99397 for established patients). This includes the reimbursement for the Pap smear collection. The insurance carrier will determine whether the service is covered, because reimbursement depends on the patient's policy.

    In some cases, private payers will reimburse for handling the specimen. If so, you can also report 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory). Specimen handling payment will vary from payer to payer, but it tends to be a minor amount. In addition, "You should bill 99000 only if the office is incurring an expense to send the specimen to the lab," Dombkowski notes.

    When submitting a preventive medicine code alone or with 99000, most private payers require one of the following ICD-9 codes alone or in combination:

  •  V72.3 -- Special investigations and examinations; gynecological examination
  •  V76.2
  •  V76.47 -- Special screening for malignant neoplasms; vagina
  •  V67.01 -- Follow-up examination; following surgery; follow-up vaginal Pap smear
  •  V45.77 -- Acquired absence of organ; genital organs
  •  V10.41-V10.44 -- Personal history of malignant neoplasm; genital organs.

    What to Do With Problem Visit and Pap

    For patients who don't have regular well-woman checkups or those who decline the Pap smear during their preventive medicine visits, the ob-gyn will perform the test when the patient presents with a problem. In this case, the smear commonly will be included in the E/M code you report for the encounter.

    For example: A woman presents complaining of stress urinary incontinence. While discussing her current problem and reviewing her chart, the doctor notes that the woman has not had a Pap smear in three years. The ob-gyn then performs an E/M service for the current problem and includes a pelvic exam and Pap smear.

    Here, again, you would include the Pap smear collection and slide preparation in the E/M code (99201-99205 for new patients, or 99211-99215 for established patients). With proper documentation, you can ethically raise the office visit to a higher level, based on the amount of medical decision-making or an additional examination, when the ob-gyn performs such services. In addition, be sure to link the E/M office visit code to the Pap screening ICD-9 code (V76.2), Dombkowski says.

    • Other Articles in this issue of

    Ob-Gyn Coding Alert

    View All