An abnormal Pap smear test does not mean you have cancer, but it could mean that you have precancerous cells or HPV.
Most abnormal Pap smears are caused by certain types of human papillomavirus, or HPV. Frequently, these viruses and the cell changes that they cause on the cervix will go away on their own. However, HPV may stay in the body for many years without causing any signs or symptoms.
Being alarmed or worried is a completely normal reaction when told your Pap smear is abnormal. An abnormal Pap smear may indicate that you have an infection or abnormal cells called dysplasia. It’s important to remember that abnormal Pap smear results do not mean you have cancer.
ICD-10 Code for Unspecified abnormal cytological findings in specimens from cervix uteri- R87. 619- Codify by AAPC.
Personal history of malignant neoplasm of breast. Z85. 3 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
R97. 20 - Elevated prostate specific antigen [PSA]. ICD-10-CM.
Rationale: Look in ICD-10-CM Alphabetic Index for History/personal/malignant neoplasm (of)/breast which refers you to Z85. 3. Verification in the Tabular List confirms Z85. 3 is for personal history of malignant neoplasm of breast.
ICD-10 code: Z85. 3 Personal history of malignant neoplasm of breast.
Z85. 3 can be billed as a primary diagnosis if that is the reason for the visit, but follow up after completed treatment for cancer should coded as Z08 as the primary diagnosis.
Elevated prostate specific antigenR97. 20 Elevated prostate specific antigen [PSA] - ICD-10-CM Diagnosis Codes.
Prostate Cancer (ICD-10: C61)
Report HCPCS Level II code G0102 Prostate cancer screening; digital rectal examination or G0103 Prostate cancer screening; prostate specific antigen test (PSA), total, as appropriate, with ICD-10-CM diagnosis code Z12. 5 Encounter for screening for malignant neoplasm of prostate (ICD-9-CM V76.
Answer: D - In the CPT manual, Appendix C lists clinical examples of evaluation and management procedures.
I would say the 99304-99310 because in the CPT guidelines for "Nursing Facility Services" it states that "these codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential treatment center..." Hope that helps.
Rationale: Medicare requires that the QW modifier be applied for all claims for payment of test performed in a site with a CLIA waived certificate.
If this is your first visit, be sure to check out the FAQ & read the forum rules.To view all forums, post or create a new thread, you must be an AAPC Member.If you are a member and have already registered for member area and forum access, you can log in by clicking here.If you've forgotten your username or password use our password reminder tool.
If this is your first visit, be sure to check out the FAQ & read the forum rules.To view all forums, post or create a new thread, you must be an AAPC Member.If you are a member and have already registered for member area and forum access, you can log in by clicking here.If you've forgotten your username or password use our password reminder tool.
Billing for pap smears in a physician practice can be confusing for clinicians. Pap smears can be screening services or diagnostic services; Performing a pelvic exam is part of a preventive medicine service or problem oriented visit
Screening Pap Tests & Pelvic Exams MLN Booklet Page 3 of 12 MLN909032 April 2022. What’s Changed? We added 3 ICD-10 diagnosis codes: Z92.850, Z92.858, and Z92.86 (page 8).
Family medicine and OB/GYNs practices regularly have women come in for their pap and pelvic exam. A Pap test is a simple and quick screening test conducted to obtain a smear of vaginal or cervical cells for cytological study.
When a patient comes back to your office for a repeat Pap smear, you need to measure your options of E/M and specimen handling codes as well as diagnosis codes.
ICD-10 states R87.615 is appropriate for “inadequate sample of cytologic smear of cervix.”
Cervical intraepithelial neoplasia I [CIN I] (N87.0)
In the CPT® Index, look for Hysteroscopy/Ablation/Endometrial, guiding you to code 58563. The LGSIL is treated with cryocautery. In the CPT® Index, look for Cervix/Cauterization/Cryocautery referring you to code 57511. Verify the codes in the numeric section. Modifier 51 is appended to 57511 to show multiple procedures performed in the same session. In the ICD-10-CM Alphabetic Index look for Abnormal/Papanicolaou (smear)/cervix/low grade squamous intraepithelial lesion (LGSIL) guiding you to code R87.612. Verify in the Tabular List.
Rationale: The patient is coming in for a subsequent (second or staged) abdominal paracentesis. In the CPT® Index look for Paracentesis/Abdomen directing you to 49082, 49083. Code 49083 includes imaging guidance so the radiology codes are not separately reported. 49083 does not have a post-operative period because it has 000 for the global days indicator. Modifier 58 is not required. Look in the ICD-10-CM Alphabetic Index for Cancer and you are directed to see also Neoplasm, by site, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/ovary and select from the Malignant Primary (column) guiding you to code C56.-. In the Tabular List a 4 th character is reported to complete the code. Malignant ascites is found by looking for Ascites/malignant which directs you to code R18.0. In the Tabular List there is a code first note under code R18.0 indicated to "Code first malignancy, such as: malignant neoplasm of ovary (C56.-); secondary malignant neoplasm of retroperitoneum and peritoneum (C78.6)." This means the malignant ascites is reported as a secondary code and the ovarian cancer is reported as the primary diagnosis code.
Rationale: In the CPT® Index look for Catheter/Bladder referring you to codes 51701-51703. CPT® code 51702 is correct to report for this scenario since an indwelling catheter (for example a Foley catheter) is left in the bladder and urine is drained. Code 51701 is used when a non-indwelling catheter is inserted to determine post void residual urine; this is sometimes called a straight cath. The patient is diagnosed with urine retention and prostate hypertrophy. In the ICD-10-CM Alphabetic Index look for Enlargement, enlarged/prostate/with lower urinary retention guiding you to code N40.1. In the Tabular List locate N40.1 and you are directed to use additional code for associated symptoms. Code R33.8 is used to describe urinary retention. Verify code selection in the Tabular List.
Rationale: Over the counter medication taken in an improper dosage is considered a poisoning. ICD-10-CM guideline I.C.19.e.5.b states "When coding a poisoning or reaction to the improper use of a medication (for example: overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50." This was an accident (taken incorrectly). In the ICD10-CM Table of Drugs and Chemicals, look for Aspirin/Poisoning, Accidental (unintentional) column directing you to T39.011. In the Tabular List this code needs a 7 th character. The seventh character chosen is A. The first code to assign is the poisoning, T39.011A. The codes for the manifestations are assigned next and are found in the ICD-10-CM Alphabetic Index by looking for Tinnitus (ringing in the ear) H93.1-, 5 thcharacter 3 for both ears; Nausea/with vomiting (R11.2); and Drowsiness (R40.0). Verify code selection in the Tabular List.
Rationale: In the CPT® Index, look for Palatoplasty 42145, 42200-42225. An alternate path is Cleft Palate/Repair which refers you to 42200-42225. Review of the code descriptions in the main section confirms code 42220 represents a secondary repair to a cleft palate. Modifier 53 is appended because the procedure was terminated after anesthesia due to extenuating circumstances. The diagnosis of a complete unilateral cleft palate is indexed in the ICD-10-CM Alphabetic Index under Cleft/palate referring you to code Q35.9. The unspecified code is the appropriate code because the surgeon did not provide specific information for the location of the cleft. Next, look for Seizure (s) (see also Convulsions) R56.9. Both listings direct the coder to R56.9 Unspecified convulsions. Code R56.9 is reported because the patient began to seize after administering the general anesthesia. Verify all code selections in the Tabular List.
Rationale: Epistaxis is the term for nasal hemorrhage. In the CPT® Index look for Packing/Nasal Hemorrhage which directs you to code range 30901-30906. 30903 represents anterior packing for an uncontrolled or extensive nasal hemorrhage. Modifier 50 indicates this was done in both nares (bilaterally). In the ICD-10-CM Alphabetic Index look for Epistaxis referring you to code R04.0. Verification in the Tabular List confirms code selection.
RATIONALE: In the ICD-10-CM Alphabetic Index look for Enlargement, enlarged/prostate/with lower urinary symptoms (LUTS) and you are directed to N40.1. In the Tabular List there is an instructional note to Use additional code for associated symptoms, when specified. Urinary reten-tion is coded with R33.8.
ICD-10 states R87.615 is appropriate for “inadequate sample of cytologic smear of cervix.”
Cervical intraepithelial neoplasia I [CIN I] (N87.0)