The beneficiary has not had a screening Pap smear test during the preceding three years (i.e., 35 months have passed following the month that the woman had the last covered Pap smear ICD-9-CM code V76.2 is used to indicate special screening for malignant neoplasm, cervix); or
Full Answer
Today let’s get back to basics with a look at how to handle diagnosis coding for repeat Pap smears. When the provider repeats a Pap smear because of an inadequate sample or abnormal results, you’ll report a code from R87.61- Abnormal cytological findings in specimens from cervix uteri.
Pap smear during a preventive medicine services for a commercial patient If the patient presents for a preventive medicine service, the pelvic exam is part of the age and gender appropriate physical exam, as described by CPT ® codes in the 99381—99397 series of codes.
R87.616, Satisfactory cervical smear but lacking transformation zone ICD-10 states R87.615 is appropriate for “inadequate sample of cytologic smear of cervix.” Medicare tip: Experts advise using the appropriate Z code, such as Z12.4 Encounter for screening for malignant neoplasm of cervix, when reporting these repeat Pap smears to Medicare.
CPT code 88143. Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and re screening under physician supervision. CPT code 88147. Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision.
Vaginal Pap test (Z12. 72) Pap test other genitourinary sites (Z12. 79)
A search in your electronic health record will often find HCPCS code Q0091, “Screening Papanicolaou smear; obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory.” Here's when to use (and when not to use) that code.
Summary of pap smear billing guidelinesIf using CPT® preventive medicine services, and also performing a screening pap smear report a code in 99381-99397 series and Q0091.If using E/M codes for a symptom or condition and practitioner also obtains a pap smear report only the E/M service.More items...
ICD-10 Code for Unspecified abnormal cytological findings in specimens from cervix uteri- R87. 619- Codify by AAPC.
Z01.419411, Encounter for gynecological examination (general) (routine) with abnormal findings, or Z01. 419, Encounter for gynecological examination (general) (routine) without abnormal findings, may be used as the ICD-10-CM diagnosis code for the annual exam performed by an obstetrician–gynecologist.
Use code Z00. 01 as the primary code as well as the codes for the chronic condition(s). When to use code Z00. 00: Patient presents for an Annual Wellness Visit (AWV).
Code 99000 is intended to reflect the work involved in the preparation of a Pap smear specimen before sending it to the laboratory. In addition to the preparation of the Pap smear specimen, it may be used for other specimens.
Medicare reimburses for a screening pelvic examination every two years in most cases. This service is reported using HCPCS code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination).
Well Women Exam CPT Code CPT G0101 may be used to report Well Woman Exam. The description of the CPT code for Well woman is as follows: “Cervical or vaginal cancer screening; pelvic and clinical breast exam.”
Z12.4 – Encounter for screening for malignant neoplasm of cervix*
Z01. 411, Encounter for gynecological examination (general) (routine) with abnormal findings, Z01. 419, Encounter for gynecological examination (general) (routine) without abnormal findings.
Atypical squamous cells of undetermined significance on610 for Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US) is a medical classification as listed by WHO under the range - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified .
The only CPT ® codes specifically for pap smears are for use by a pathologist, for the interpretation of the cytology specimen. CPT® codes in the lab section, 88000 series, should not be reported by the office physician who collects the pap smear. Those codes are used by the pathologist who provides the interpretation of the pap smear.
If the patient presents for a preventive medicine service, the pelvic exam is part of the age and gender appropriate physical exam, as described by CPT ® codes in the 99381—99397 series of codes. However, for a screening pap, the HCPCS code for obtaining the screening pap smear, Q0091 may be used. Although this is a HCPCS code developed by Medicare for Medicare patients, many commercial payers recognize the code. Do not bill G0101, pelvic and clinical breast exam, on the day of a CPT preventive visit. CPT codes 99381–99397 include an age and gender appropriate history and physical exam. Billing G0101 would be double billing for that portion of the exam.
Q0091 Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory (Obtaining screen pap smear)
Do not report Q0091 because it is for obtaining a screening test. Use G0101 and Q0091 for Medicare patients receiving a screening pelvic and breast exam and having a screening pap smear. There are frequency limits for this service. Applying the 2021 office visit guidelines is challenging.
The pelvic exam that the provider does is part of the E/M service . There isn’t a code to separately bill the pelvic exam that is part of a problem-oriented visit. It would be incorrect to bill the HCPCS code Q0091 for obtaining a screening pap smear, because the purpose of the visit and the pap is not screening.
Do not report Q0091 for obtaining a diagnostic pap smear performed due to illness, disease or a symptom.
There is no code for performing the breast exam alone on a Medicare patient who does not need the remainder of the screening exam elements.
A Screening Pap Smear (HCPCS code Q0091) and/or the Cervical or Vaginal Cancer Screening (G0101) is considered part of a preventive or problem based office visit and is not separately reimbursable. As of February 21, 2011, the screening services of Q0091 and/or G0101 are considered for separate reimbursement when reported in addition to a significant and separately identifiable E/M service. Modifier 25 must be appended to the E/M service for the screening services to be separately reimbursed. Documentation supporting the unrelated E/M service meeting the Modifier 25 requirements must be maintained and made available to us upon request. Exception: Q0091 and G0101 will remain a component of a Preventive Medicine E/M Service and will not be separately reimbursed. Modifier 25 appended to the Preventive Medicine E/M CPT Codes will not override the edit (Preventive Medicine E/M CPT codes 99381- 99397).#N#DIAGNOSTIC CODING FOR THE COLLECTION OF PAP SMEAR AND SCREENING PELVIC EXAM
Insurance considers the collection of the pap specimen to be included in the E&M code when services are provided for a gynecological (GYN) exam (Procedure codes 99381 through 99397).
Q0091 Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory NOTE: Another specimen may be collected in situations where unsatisfactory screening Pap smear specimens have been collected and conveyed to clinical laboratories that are unable to interpret the test results. To bill for this reconveyance, annotate the claim with HCPCS code Q0091 along with modifier -76 (repeat procedure or service by same physician or other qualified health care professional).
These risk factors include infection with Human Papillomavirus (HPV), smoking, immunosuppression, Chlamydia infection, diet, oral contraceptives, multiple full-term pregnancies, young age at the first full-term pregnancy, poverty, diethylstilbestrol (DES), and a family history of cervical cancer.1 HPV, a sexually transmitted infection, has been strongly linked to cervical cancer. It has been stated that the demonstration that cervical cancer is caused by the persistent infection by certain genotypes of HPV is one of the most important discoveries in the investigation of cancer etiology over the past 25 years.6
Q0091 Screening Papanicolaou smear; obtaining , preparing and conveyance of cervical or vaginal smear to laboratory
As, there are often no symptoms of cervical dysplasia until the disease has progressed into advanced cancer, it is crucial that sexually active women, or women over age 20, have yearly Pap smears. In addition, women who experience bleeding between menstrual periods, bleeding after intercourse, abnormal vaginal discharge, abdominal pain or swelling, urinary symptoms, or pelvic pain should be evaluated by a healthcare provider, even if it is not the regular time for a Pap test.
Collection of a diagnostic Pap smear (performed due to illness, disease, or symptoms indicating a medically necessary reason) is included in the physical examination portion of a problem-oriented E/M service and is not reported or reimbursed separately.
Pt is then coming to you (obgyn) for the well woman. 99383-99397 is the appropriate coding for the obgyn with Z01.419 or Z01.411 (and of course any other applicable dx for the patient.) Most carriers have appropriate claim checks in place to recognize the separate specialty and/or diagnosis. If a claim gets denied due to the 2 preventive services in a year, typically a phone call or online request will resolve it. Otherwise, an appeal letter will be required. While it is 2 preventive services in a year, the scope of those 2 services are very different.
Q0091 is used by Medicare as well as commercial carriers. Some payors will bundle the Q0091 into an E/M.
If the clinician just took the PAP sample without providing additional services, then you should not bill for them. G0101 I have seen covered by some commercial carriers, but most ob/gyns are billing the 99381-99397 instead for an annual well woman. Q0091 is used by Medicare as well as commercial carriers.
Z00.00 is required for Medicaid. They will deny Z01.419. For Medicare, I use G0101 and Q0091 with Z01.419, Z12.4 or Z01.411, unless they are high risk. Medicare covered codes for low risk: Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.80.
If the patient already came in within the year for annual well exam and you already billed 99381-99397, you may not get it covered a second time. POSSIBLY with appeal and showing the diagnosis of gynecological exam.
I will make another side note that in my area, it would be highly unusual for a PCP to do a PAP (like I've never seen it once in 16 years highly unusual). They would refer the patient to an ob/gyn and wouldn't even have the stirrups, speculum, PAP brush, etc. if the patient requested the service. In other parts of the country (particularly more rural areas with less access to ob/gyn care), it is a more common practice.
Use following CPT codes for Diagnostic Pap smear billing and coding. 88141-88143.
Covered in every 12 months in case if patient has high risk for cervical or vaginal cancer, in childbearing age and had an abnormal Pap test in the past 36 months. Refer to the CMS National Coverage Determination (NCD) for high-risk criteria.
Medicare provides coverage for both screening and Diagnostic Pap smear and correct way of billing and coding Pap smear depend upon choosing the right CPT code for Diagnostic and screening pap smear. A cervical screening test (previously known as a smear test) is a method of detecting abnormal cells on the cervix.
ICD-10 states R87.615 is appropriate for “inadequate sample of cytologic smear of cervix.”
Cervical intraepithelial neoplasia I [CIN I] (N87.0)
CPT codes for Pap smear are (88141-88175) and HCPCS Codes use to report for both screening and Diagnostic pap smear. List of HCPCS codes and CPT codes for Pap smear coding and billing Commercial insurance and Medicare.
Reporting HCPCS code Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). Q0091 is a code developed by Medicare for services provided to Medicare patients. Medicare does not reimburse for comprehensive preventive services, such as those reported with CPT-4 codes 99384 – 99397. Medicare allows payment of code Q0091 as an exception to its general rule since there would otherwise be no reimbursement for the collection service. Providers
However, collection of a diagnostic pap smear for a Medicare patient (performed due to illness, disease, or symptoms indicating a medically necessary reason) is included in the physical examination portion of a problem-oriented E/M service and is not reported or reimbursed separately.
Medicare Part B covers screening Pap tests and pelvic exams (including clinical breast exam) for all female patients when ordered and performed by 1 of these medical professionals, as authorized under state law:
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSAR apply. CPT is a registered trademark of the American Medical Association. Applicable FARS/HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.