Pathology/Lab Coding Alert

When your lab gets a Pap test order, you need to answer three key questions if you want to get the coding right — and garner the pay your lab deserves.

Study the following example to zero in on the questions and answers that will ensure proper Pap test coding and pay for your lab.

Pap Case

The clinician ordered Pap test for a 37-year-old woman who has no symptoms, but has not had a Pap smear in four years. Your lab performs a thin-layer preparation screened

by an automated system with manual rescreening, and reports findings of atypical squamous cells of undetermined significance (ASC-US). The pathologist interprets the abnormal slide and confirms the ASC-US diagnosis.

The clinician sends a follow-up Pap specimen in three months. Your lab performs the same Pap procedure that results in the same findings (ASC-US), but the pathologist interpretation provides a final diagnosis of atypical squamous cells, cannot exclude high grade squamous intraepithelial lesion (ASC-H).

Your job is to read the case, answer the following questions, and come up with the correct procedure and diagnosis codes.

Question 1: What is the Reason for the Test?

The lab performs the initial Pap test as a screening because the clinician orders the test with no signs and symptoms of disease for a patient who has not had a Pap test in four years.

The ordering clinician will probably order the screening Pap test using Z12.4 (Encounter for screening pap smear for malignant neoplasm of cervix). But if the test is part of a routine gynecological exam, you can expect the clinician to order the Pap test using one of the following codes:

• Z01.419 (Encounter for gynecological examination (general) (routine) without abnormal findings)
• Z01.411 (Encounter for gynecological examination (general) (routine) with abnormal findings)

Screening: When the physician orders a screening test, that means the patient has no known current problems or past history of abnormal Pap results or cervical disease, explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M.

Caution: If the physician orders the Pap test using Z01.411, you’ll need to ensure that the patient doesn’t have signs and symptoms that indicate the Pap test is diagnostic, which could lead to a different procedure coding scenario depending on the payer (see question 2). You may need to request that the ordering physician clarify by adding a specific symptom code or by adding the routine screening code Z12.4.

Report findings: Because the Pap test demonstrates abnormal findings, you’ll need to report a secondary diagnosis code to indicate the test results, which in this case is R87.610 (Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)).

Second test: The physician orders a three-month follow-up Pap test based on the initial Pap test findings, so you’ll need to report R87.610 as the ordering diagnosis for this subsequent test. Without that diagnosis, most payers would deny payment for a second Pap test reported within the same year.

Again, you’ll need to report the findings from this second encounter, which means listing the secondary diagnoses based on the pathologist’s findings: R87.611 (Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix (ASC-H)).

Question 2: Who is the Payer?

The preceding case example doesn’t indicate the payer, but you’ll need to know that information when you’re coding the services. Medicare requires different procedure codes than you’ll use for non-Medicare payers, so we’ll cover both options.

Medicare: Rather than accepting CPT^® Pap test codes for screening Pap tests, Medicare requires you to choose the appropriate HCPCS Level II code for the service from the following options:

• P3000 (Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision)
• G0123, G0143-G0145 (Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation …). The difference between these codes is whether in initial screening is automated or manual, and whether the test includes rescreening.
• G0147-G0148 (Screening cytopathology smears, cervical or vaginal, performed by automated system … ). These two codes differ by whether a manual rescreening takes place.

Interpretation: Medicare also provides three different physician Pap interpretation codes, which pair with the specific screening code as follows:

• G0124 (Screening cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician). Use with screening codes G0123 or G0143-G0145.
• P3001 (Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician). Use with screening code P3000.
• G0141 (Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician). Use with screening codes G0147 and G0148.

Non Medicare: For most other payers, or for diagnostic Pap tests for Medicare beneficiaries, you’ll turn to a different set of CPT^® codes, as follows:

• 88142-88143 and 88174-88175 (Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation …)
• 88150-88153 (Cytopathology, slides, cervical or vaginal …)
• 88164-88167 (Cytopathology, slides, cervical or vaginal (the Bethesda System) …)

The differences within each of these code families also accounts for manual or computer assisted screening, and rescreening variations.

If the pathologist interprets a Pap test reported with any of the preceding codes, you should report the interpretation as 88141 (Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician), says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Question 3: What is the Lab Test Method?

Despite Medicare requiring a HCPCS Level II codes instead of CPT^® codes for these services, you can see that the primary difference between the many code choices is the lab method. The different lab methods account for factors such as traditional cytopathology or thin-layer preparation, manual or computer assisted screening, Bethesda reporting system or not, and whether the evaluation involves rescreening.

For instance, your lab might report the test in this case using 88175 (Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision) or the Medicare equivalent G0145 (Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision).

For the associated physician interpretation, you would report 88141 or G0124.