Primary Care Coding Alert

Pap smears are covered every two years for low-risk Medicare patients and annually for high-risk patients. But, family practice coders may face uncertainty when the physician has to perform the initial Pap smear or repeat the test. Understanding how to code the initial Pap will help coders when the repeat is performed.
 
"Sometimes a doctor receives abnormal results back from the lab and decides to repeat the test either to confirm the first result or to followup on the first result," says Melanie Witt, RN, CPC, MA, an independent coding consultant based in Fredericksburg, Va. "The second test is now diagnostic and not a screening like the first, and that changes the coding."
Coding the Initial Pap
Medicare and private payers differ in their coverage of Pap smears as screening tests for high-risk patients. "High risk does not mean they had breast cancer, for example, because then it's not a screening, it's a diagnostic test," Witt says. A history of cancer usually prompts a diagnostic test. "There are specific criteria the patient must meet to qualify as high risk." A Medicare patient must have one of the following to be considered "high risk":

  History of HIV (V08 or 042)
  History of STDs (V13.8)
  Five or more sexual partners in her lifetime (V69.2)
  Onset of sexual activity before the age of 16 (V69.2)
  Diethylstilbestrol (DES) exposure (760.76)
  History of no Pap smears in the last seven years   (V15.89)
  Absence of three consecutive negative Pap results     (795.0)
  Any gynecological problem (such as cervical or vaginal cancer or genitourinary system problem) in the last three years if the patient is of childbearing age.
 
 
"Medicare does not pay for an annual pap smear for any reason other than the ones stated above," Witt says. "If the patient has any other condition that the physician thinks makes her at high risk, he will either have to indicate that he is doing a diagnostic Pap smear or have to go along with the low-risk rules as stated by Medicare."
 
Tip: Practices may be uncomfortable asking Medicare patients questions relating to the above criteria. Put the questions on the history form the patient fills out before the visit. Above the questions include the phrase "if any of the following conditions are checked, Medicare covers the exam annually," or a similar statement. The physician is going to confirm the information with the patient and include it in the official documentation, as required by Medicare. 
 
The taking of the Pap smear specimen is considered part of the examination and should not normally be coded separately from the preventive service (99381-99397) or problem E/M visit (99201-99215). In some cases, private payers may reimburse for the handling of the specimen. [...]