Ob-Gyn Coding Alert

Question: Our ob-gyn recently performed a repeat Pap smear for a woman as her Pap smear taken earlier a few months back had some abnormalities. Should I report a preventive service code for the visit or should I report it with some other code? Also, tell me what diagnosis code should I report for the encounter?

Rhode Island subscriber

Answer: When your ob-gyn performs a repeat Pap smear as the previous Pap smear showed abnormalities, you should not reach out to a preventive service code (such as 99394-99397, Periodic comprehensive preventive medicine reevaluation and management of an individual ...) as your clinician performed the repeat of the Pap smear due to the abnormalities. Also, because the ob-gyn likely performed the previous Pap smear as part of a preventive service (e.g. an annual well-woman exam), the current visit likely does not repeat all of the elements (e.g., an age and gender appropriate history and examination, counseling/anticipatory guidance/risk factor reduction interventions) that might otherwise permit you to report a preventive service code for the current visit.

If your ob-gyn is repeating the Pap smear due to the abnormalities detected in the previously taken Pap smear, you will have to report an appropriate evaluation and management (E/M) code for the visit. If no other E/M service was performed during that encounter, it is most likely that you will only be able to report a low level E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the encounter. This would apply whether the patient was Medicare- or commercial payer-eligible. Remember that the collection of the Pap specimen is included in the E/M service billed. And starting this year, you may also be able to bill the new add-on code +99459 (Pelvic examination (List separately in addition to code for primary procedure)) if a full pelvic exam was also performed when the Pap smear was collected. Remember, this code is not meant to cover the Pap collection itself. Refer to the articles, “Federal Register Clarifies Pelvic Exam Add-on Code,” featured in Ob-gyn Coding Alert, volume 27, number 1, and “+99459: 5 FAQs Clarify How to Use This Expense Only Code” featured in Ob-gyn Coding Alert, volume 27, number 3 for more information.

For reporting the diagnosis for the encounter, you will need to report one of the appropriate codes from R87.61- (Abnormal cytological findings in specimens from cervix uteri…). If specifics about the abnormalities detected in the previous encounter are available, you should report the most appropriate code from the above-mentioned range of codes. If there is no specific information about the type of abnormalities that were detected, you will need to report R87.619 (Unspecified abnormal cytological findings in specimens from cervix uteri).