Pathology/Lab Coding Alert

Follow these 5 steps to improve your Pap reimbursement With more than two dozen procedure codes, different coverage rules for screening versus diagnostic tests, and changing diagnosis coding requirements, you've got a lot to keep track of when reporting cervical cancer lab tests. "But you can minimize claim denials if you report Pap and ancillary tests according to the following five steps," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Professional Coding and Compliance Consulting in Manassas, Va. 1. Determine if Pap Test Is for Screening Physicians order screening Pap tests at regular intervals for patients with signs of disease. "If a patient presents with symptoms or a personal history that indicates a need for the test, the Pap smear would not be considered screening," says Melanie Witt, RN, CPC, MA, an independent coding educator based in Fredericksburg, Va.
 
Medicare has established coverage rules for screening Pap tests that many other payers follow regarding frequency and test type. Coding is often different, however, because Medicare prescribes specific HCPCS Level II codes for its screening exams. See the table on page 92 for a complete list of the codes.
 
The rules for screening Pap tests distinguish between high-risk and low-risk patients. Medicare covers Pap screening for low-risk patients once every two years, and high-risk patients once a year. Medicare considers patients who have any of the following documented risk factors to be high-risk: early onset of sexual activity, multiple sexual partners, history of sexually transmitted disease, fewer than three negative Pap smears within the previous seven years, and daughters of women who took DES (diethylstilbestrol) during pregnancy.
 
Based on risk level, you should report one of four diagnosis codes to designate the reason for the Pap screening. Report V15.89 (Other specified personal history presenting hazards to health; other) for annual screening Pap smears for high-risk patients. For biennial Pap smears for low-risk patients, report V76.2 (Special screening for malignant neoplasms; cervix), V76.47 (Special screening for malignant neoplasms; vagina), or V76.49 (Special screening for malignant neoplasms; other sites). Medicare has indicated that you may use either V76.47 or V76.49 for patients who are post-hysterectomy for a nonmalignant condition.

2. Use Different Codes for Diagnostic Pap Physicians order diagnostic Pap smears based on symptoms or disease history. "Remember that a Pap test is either screening or diagnostic based on the reason the physician ordered the test, regardless of the results," Witt says.
 
A wide range of ICD-9-CM codes may indicate medical necessity for diagnostic Pap tests, including conditions such as a prior abnormal Pap (795.09, Other nonspecific abnormal Papanicolaou smear of cervix) or history of cervical [...]