Pathology/Lab Coding Alert

Medicares directives for reporting Pap smears can be confusing, but understanding and complying with the rules is the key to appropriate reimbursement. Selecting the correct code depends on knowing the reason for the test, as well as the lab methods used, states Paula Richburg, BS, MHA, director of laboratory services at QuadraMed Corp, a healthcare information technology firm in Bethlehem, Penn.

The first question you need answered is whether the Pap smear is ordered for screening or diagnostic purposes, says Richburg. Medicare explicitly states that the code selection is always based on the reason the test was performed, regardless of the results of the test (Health Care Financing Administration [HCFA] program memorandum AB-98-71). The answer to this question will lead to two different groups of codes, she continues. Pap smears conducted by the same method and reporting system will have a different code depending on the purpose for the test, she concludes.

Diagnostic vs. Screening Pap Smears

When a Pap smear comes to the lab, the only way to know if its for diagnostic or screening purposes is to have the ordering physician tell you, says Mary Lou Fusillo, MT (ASCP), MS, MPA, laboratory manager at North Shore University Hospital, in Manhasset, N.Y. Thats why weve revised our protocol and changed our requisition form for Pap smears, she continues. The form requires an ICD9 Codes assignment by the physician, which points us in the direction of the screening or diagnostic codes.

The difficulty arises because although the physician assigns the diagnosis code, HCFA holds the lab responsible for making sure that the code meets Medicare coverage criteria, continues Fusillo. The solution, discussed in the Office of Inspector Generals (OIG) Compliance Program Guidance for Clinical Laboratories, is for labs to provide their physician clients with information regarding Medicare criteria for Pap smears.

The Medicare criteria for Pap smears center on the reason for the test, which is reflected in the selection of appropriate ICD-9 codes, states Fusillo. According to Medicare, screening Pap smears are those that are performed in the absence of signs or symptoms of disease. Medicare covers these once every three years, or more often if the patient is considered at high risk for cervical or vaginal cancer.

Because screening Pap smears have a frequency limitation for reimbursement, it is wise to get an Advance Beneficiary Notice (ABN) signed by the patient if the physician hasnt already done so, advises Fusillo. By signing the ABN, the patient agrees to pay for the service if the claim is denied. Then the lab can bill the patient if he or [...]