Pathology/Lab Coding Alert

Question: If our lab runs a screening Pap smear but the findings are abnormal, should we list the screening ICD-9 code or the diagnostic findings?

Connecticut Subscriber

Answer: The answer is both.

ICD-9 coding instructions indicate that if a physician makes a confirmed diagnosis based on the results of a diagnostic test, you should report the confirmed diagnosis rather than the ordering physician's clinical diagnosis.

Pap screening tests for Medicare patients represent an exception to this rule. In those cases, you should always use the ordering physician's clinical diagnosis -- which is a screening code. Labs typically report V76.2 (Special screening for malignant neoplasms, cervix) as the ordering diagnosis for screening Pap tests. If the Pap screening is normal, you don't report any other ICD-9 code.

Use additional code: If the findings are abnormal, you should still list the screening code (V76.2) first, but you should also list an ICD-9 code for the findings. For instance, for a cervical Pap smear showing mild cellular changes of unknown cause, you would report 795.01 (Abnormal Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]).

Don't miss: Some private insurers and Medicaid agencies follow the same policy for Pap smear coding, so you should check with your payers to determine how to code non-Medicare screening Pap smears.