Pathology/Lab Coding Alert

Question: When a clinician orders a screening Pap smear using an ICD9 Codes such as V76.2 and the pathologist finds an abnormal smear, such as ASCUS (795.01), which ICD-9 code should we use for billing - V76.2 or 795.01?

Ohio Subscriber

Answer: Because this is a screening test, you must report the "reason for the test" as the primary ICD-9-CM diagnosis code, regardless of the test results. That means you should bill the test using V76.2 (Special screening for malignant neoplasms; cervix). You may report the findings (795.01, Atypical squamous cell changes of undetermined significance favor benign [ASCUS favor benign]) as a secondary diagnosis.
 
This is in accordance with Medicare's guidelines outlined in program memorandum AB-01-144. CMS states, "When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the physician interpreting the diagnostic test should report the reason for the test (e.g., screening) as the primary ICD-9-CM diagnosis code. The results of the test, if reported, may be recorded as additional diagnoses."
 
Screening tests are an exception in this regard. In the same communication, CMS states that for diagnostic tests ordered due to signs and/or symptoms, "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis."
 
For clinical laboratory tests that do not require physician interpretation, you must bill the test using the diagnosis provided by the ordering physician, according to CMS program memorandum B-03-046. The lab should obtain the ICD-9-CM code or a narrative diagnosis from the ordering physician for billing purposes.

 - Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.