Ob-Gyn Coding Alert
Repeat Pap For an Ob Patient
Question: On the original ob visit on 9/9/16, the doctor performed the Pap smear, which came back with low-grade squamous intraepithelial lesion (LSIL). Patient came back on 10/7/16 and had another Pap because of the LSIL. Can we bill insurance for this repeat Pap visit?
Coding Institute Forum Contributor
Answer: Yes, as the initial one was abnormal. However, you will be billing an E/M service only for this (low level probably, such as 99211, Office or other outpatient visit for the evaluation and management of an established patient …) and you will not bill for the collection of the Pap, which is included in the E/M.
Your diagnosis will be LSIL (R87.612), not an ob complication code— assuming the ob-gyn has documented that this problem is incidental to pregnancy. That means the payer should reimburse for this visit outside of global currently and not send a denial for later appeal.
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