Learn How to Code a Repeat Pap Smear Plus UTI Evaluation
Question: A Medicare patient who is high risk due to their sexual behavior came in for their annual wellness visit. The ob-gyn did a Pap, and the office reported G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) with Q0091. The ob-gyn ordered a repeat Pap six months later due to insufficient cells. The patient came back to have the repeat Pap, but they also complained at the visit that they had urinary frequency and pain. The ob-gyn evaluated the patient for a urinary tract infection (UTI). How should I code the repeat Pap? Should I report it with Q0091 again? Maine Subscriber Answer: Yes. You should report Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the repeat Pap smear. Don’t forget to append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional). Your diagnosis code will be Z12.4 (Encounter for screening for malignant neoplasm of cervix) if the first smear was inadequate. As for the UTI, you should bill a separate evaluation and management (E/M) service (99211-99215 [Office or other outpatient visit for the evaluation and management of an established patient ...]) and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). You should report the UTI with N39.0 (Urinary tract infection, site not specified). Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
