Revenue Cycle Insider

Question: The lab performed a liquid-based Pap test that the physician ordered, which we billed to Medicare as G0144. The claim was denied because it turns out the patient had a prior Pap test nine months ago. How can we get paid for the test?

Revenue Cycle Insider Subscriber

Answer: Medicare was correct to deny a claim for a screening Pap test within nine months, as their frequency limitations only allow for annual screens “at least 11 months after the most recent screening Pap test,” according to the Medicare Learning Network booklet Screening Pap Tests & Pelvic Exams.

However, there are two scenarios in which you will be able to get paid for a Pap test conducted before the 11 months have elapsed.

Scenario 1: The physician orders the test based on signs or symptoms such as an abnormal finding on the patient’s last Pap test.

In this case, the test is considered diagnostic and is not subject to the same frequency restrictions. To get Medicare to pay for the test, you will then have to document the appropriate diagnosis code, such as R87.619 (Unspecified abnormal cytological findings in specimens from cervix uteri). Additionally, you should not bill the test using Medicare code G0144 (Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision). Instead, you should submit the claim with the correct procedure code for a diagnostic Pap test, such as 88174 (Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision).

Scenario 2: The physician orders a screening Pap test using a diagnosis code such as Z12.4 (Encounter for screening for malignant neoplasm of cervix), but you have a signed advance beneficiary notification (ABN), which indicates that the patient is aware the test may not be covered and they will be responsible for payment.

If you do have a signed ABN, you will need to append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) to the test code. Having the signed ABN will then allow you to bill the patient for the test.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC