Ob-Gyn Coding Alert

Discover if your responses to questions 1-4 are spoton, or if you need to dig deeper into Pap smear coding concepts.

A low-risk non-Medicare patient returns to the ob-gyn upon receiving a finding of atypical squamous cells of undetermined significance (ASC-US) after her last visit. The ob-gyn performs another Pap smear.

Answer: C. Pap smear collection is usually included in the E/M service.

Trap: Resist temptation to report the test separately (using +88141, Cytopathology, cervical or vaginal [any reporting system]; requiring interpretation by physician, for example). Ob-gyns aren't usually the provider who screens the smear -- a lab is. Therefore, the lab would charge for the screening, not the ob-gyn. Also, reporting 88141 means you're telling the payer that the Pap was difficult to read and required the interpretation of the pathologist, not just the lab technician.

A low-risk Medicare patient arrives at your office and undergoes an annual Pap smear and pelvic and breast exam. How should you code this scenario?

Answer: E

Watch out. This is a trick question. Medicare does not pay for an annual Pap smear for low-risk patients.

You have to make sure you are both careful with the coding and explaining fully to patients what is and is not covered. "The biggest battle I have is with patients who sign advance beneficiary notices (ABNs), listen to the receptionist explain the form, and then still come back wondering why they have a bill," says Cindy Foley, billing manager for three gynecology practices in Syracuse, N.Y. "These patients need to understand that if their policy does not cover routine tests, they may receive a bill."

High-risk: Medicare will pay for annual exams for high-risk patients, however. If the patient qualifies, you would report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the breast  and pelvic exam and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the Pap smear. Be sure to report V15.89 (Other specified personal history presenting hazards to health; other) in addition to a secondary code such as:

• 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 (V72.32)

• 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.

Low-risk: For a low-risk patient who has not been seen in 24 months, you should report V76.2 (Special screening for malignant neoplasms; cervix) or V72.31 (Routine gynecologic examination) as the diagnosis code. Medicare now allows you to report V72.31 with both the Q and G codes when the ob-gyn does both the exam and screening at the same visit.

Even though the non-Medicare patient does not complain of any problem, the ob-gyn performs a Pap smear as part of a well-woman examination.

Answer: D

In this circumstance, you should report one of the preventive medicine codes. Use 9938x or 9939x depending on age, says Lisa Leach, CCS-P, coding specialist at West Texas Medical Associates in San Angelo. These codes include the reimbursement for the Pap smear collection.

Note: A few carriers may also reimburse for specimen handling, although that may be a minor amount. If so, you can use 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory).

A patient who has not had a Pap smear in three years presents complaining of stress urinary incontinence. The ob-gyn performs a pelvic exam and Pap smear.

Answer: F

Another trick question.

First of all, the pelvic exam is related to the presenting problem. This means you can bill the Pap collection, which at this point is screening, separately with Q0091 and a diagnosis of V76.2, Foley says.

Next, you would report an E/M service (99201-99213, Office or other outpatient visit ...). Remember to 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 the E/M code, which is separate and significant from the Pap collection. Include the diagnosis of 788.3x (Urinary incontinence) or 625.6 (Stress incontinence, female),depending on the type.