Wiki Denial for HPV

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VickiS

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We are getting denials from Health Advantage of Arkansas for dx code 795.05 for 87621 CPT on patients under 30 who have ASCUS or abnormal pap smear they said it is because of dx code we are using and they are denying as provider writeoff and we can't bill patient!!! The doctor that is doing pap smear is ordering this test.. and it is a positive result..what are we to do?
 
if it was ordered as a screening then you need a screening V code. If it was ordered due to the patient is symptomatic then use the symptoms.
 
The code 795.05 is for HPV positive only. You can be HPV positive and still have "normal" cells. I would code ASCUS as 795.01. Also look at 795.02 to 795.04 for low grade to high grade abnormalities. I think the problem is specificity.
 
It is ordered as a result of abnormal pap and the hpv (high risk) dna test states detected, so you are saying use 795.01 instead of 795.05 which in the coding book 795.05 is cervical high risk HPV DNA test positive... and what about the provider write off of full fee?
 
So what you have is a patient with an abnormal PAP and now being tested for HPV. A lab cannot be coded for the result until the provider reviews it an renders the dx. Therefore use the 795.01 since that is what is known and is the reason for the test.
If you resubmit as a corrected claim and it processes as correct and pays then there will be no provider write off. If you chose to not resubmit or any that are out of timely filing you do need to write off. You cannot hold the patient responsible due to not using the correct dx code.
 
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Are you the lab that processed the specimen or the phsyician office that submitted the specimen. I am sorry but i am confused. If you are the provider that performed the PAP, then are you saying you held the claim and waited for the result.
 
We are the lab that processed the pap smear and HPV test, sorry I'm just really frustrated with all this, Health Advantage is the only insurance we are having this issue with. Thanks for all your help.
 
The denial was services not covered with diagnosis, we used 795.05 because pap was ASCUS and HPV was ordered by Doctor that sent pap smear to our lab , the result of the HPV test was positive so thats why 795.05 was used, they paid pap smear, denied HPV testing, the person that works our denials sent corrected claim changing code from 795.05 to v76.2,795.01,795.05 in that order...and sent it out yesterday...I don't think we should of changed dx code because the dx 795.05 is valid in this case.
 
Follow up - Do Not Give Up! Please call them

Have you called Health Advantage and ask them why? I found out the best way to deal with denials is to call them directly. Talk to someone specifically about the claim. I had a problem with a different insurance company(s) and it actually came down to them thinking I was offering an HPV vaccination like Gardasil when I was actually having a lab done to a patient to test for it.

Also when you code an HPV positive for screening it should be V73.81, 079.4 or if it is diagnostic you use whatever the code was assigned for the reason for the HPV to be done. So if it was LGSIL or ASUS or malignant neoplasm you will use whatever diagnosis code the physician ordered it to assign that diagnosis code.

Thanks for allowing me to offer my opinion on this,
Dana Chock, CPC-A, CCA, CANPC, CHONC
Anesthesia, Pathology, and Laboratory Coder
2013-14 Brainerd Lakes AAPC Chapter President
 
I'll have to agree with Debra Mitchell's post #5; the clinical indication/reason for test in this case is based on the Pap: a) if the Pap was a screening, and the HPV was ordered at the time of service then the HPV needs to be linked to the screening V73.81 code; but b)if the HPV was added after the abnormal Pap result was reported to the clinician, then the abnormal Pap result (795.01, etc.) is the clinical indication for the HPV test. The result of the HPV test is not known at the time is is ordered, so should not be used as the primary diagnosis for HPV test.
 
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It is my understanding that 079.4 is only for use with histological specimens, not gyn cytology.
 
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