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One of the most common procedures performed in the gynecologists offices is the collection of a screening Papanicolaou smear. According to the National Cervical Cancer Coalition, All women who are or have been sexually active, or have reached age 18, should have Pap tests and physical exams regularly. Because of the strong connection between cancer prevention and Pap smears, assuring patients are tested is a high priority for ob/gyn practices. But coding for Pap smears is full of confusion. Physicians, nurses and billing staff often think they should be able to bill one of the many cytopathology smear codes starting with 88141, says Deb Lief, CPC, president of the North Texas Chapter of the American Academy of Professional Coders and manager of coding compliance for ProMedCo, a practice management firm in Fort Worth, TX. Encounter forms often have several of these codes listed for the provider to check off, and they think they will get paid separately for performing a the test. But Pap smear collection is part of the well-woman exam -- a component of the comprehensive procedure. And this is a big educational issue for the staff, Lief explains. This article examines the various complexities of coding for Pap smears by considering the various situations that may effect your reimbursement.
Annual Well-Woman Check
Many Pap smears will be performed when the woman presents for her annual well-woman check-up. The patient has no other problem, and the physician simply does a Pap smear as part of the comprehensive preventive medicine examination. This service includes obtaining the Pap and making the slide. It should be billed using one of the preventive medicine codes (99384-99387 for new patients or 99394-99397 for established patients). Whether a patients insurance covers preventive services will depend on the policy and payer.
Dont feel badly about billing your patient for their well-woman exam if their insurance does not cover it, Lief says. Most insurance companies have non-covered services and the patients voluntarily enter into a contract with the company. Youre providing a potentially lifesaving procedure, so dont apologize. Have them pay before they leave the office.
When Pap Smear is Attached to Problem Visit
The results of a new Gallup survey of womens attitudes, knowledge and behavior regarding Pap smears, commissioned by the College of American Pathologists, points out that nearly 40 percent of American women risked their lives by not having a Pap smear in the last year. The most cited reason was a lack of time. The result of this fact is that gynecologists often find themselves performing Pap smears when patients are seen for problem-oriented evaluation and management office visits.
For example, a woman presents to her gynecologist with occasional stress incontinence. While discussing the current problem with the patient and looking over her chart, the gyn discovers the patient has not had a Pap smear since her last visit three years ago. The physician then performs an evaluation and management service for the current problem, but also performs a pelvic exam and Pap smear.
Once again, there is no special code for performing the pelvic and Pap smear. But according to Lief, the provider should include the pelvic and screening Pap in their decision process when determining the level of office visit. With proper documentation, the performance of such services can ethically raise the office visit to a higher level.
Billing Medicare for Screening Exams
Last year Medicare expanded its screening coverage beyond just Pap smears to include a screening pelvic exam and breast exam. Medicare also clarified that it would pay for annual screening exams on high-risk women, and once every three years on all others (for complete coverage see OCA June 1998, page 22). What hasnt been clear is exactly how to code for these screening services.
According to HCFA guidelines, when a Medicare patient presents for her Pap smear, pelvic and breast exam, the service can be billed to Medicare using the HCPCS Q0091 (collecting the Pap smear specimen) and G0101 (performing the pelvic and clinical breast examination). HCFA has said that it is permissible to use both codes for the same encounter, but they will only reimburse for these codes if the patient is eligible for the service in the year you are billing for it. They pay about $27 for the collection of a Pap smear specimen and about $28.50 for the pelvic and breast exam.
Note: The required elements of the full breast and pelvic exam are outlined in the issue of OCA mentioned above.
Remember to check with your local Medicare carrier, says Lief. For services furnished on or after January 1, 1999, separate payment is allowed for the physicians interpretation of a Pap smear (using code 88141) for any patient as long as: 1. The laboratory screening personnel suspect an abnormality; and 2. The physician reviews and interprets the Pap smear. Our experts clarify, however, that if a pathologist has reviewed the slide, the physician who ordered the Pap smear will not be allowed to bill for the interpretation as well.
Pap Smear Diagnosis Codes
The correct diagnosis code to use for a well-woman check-up that includes a Pap smear is V72.3 (gynecological examination: Papanicolaou smear as part of general gynecological examination). However, it is important to note that currently Medicare carriers will only accept V76.2, (screening for malignant neoplasms, cervix, routine cervical Papanicolaou smear). Even with Medicare now covering pelvic and breast screening exams, they will not accept V72.3. ACOG states they are currently working to correct this problem with HCFA.
If a Medicare patient is having an annual pelvic, Pap smear, and breast exam (because they correctly fall into Medicares high-risk designation), Medicare will only accept the diagnosis code V15.89 (personal history presenting hazards to health) for this service.
Collection of the Specimen
In search of dwindling revenues, some ob/gyn practices have been questioning whether they can find extra reimbursement in Pap smear collection. But according to ACOG, the collection of the Pap smear specimen and the preparation of the slide are always parts of a gynecology examination and should not be coded separately. This means that it is not appropriate to code a handling fee for collecting the specimen, except in those unusual cases where additional resources that are paid for by the practice are involved. This could include buying special preservative or fixative materials, or having practice staff take the specimen to the laboratory. These additional costs can be coded using either 99000 (transporting specimens) or 99070 (unusual supplies). The Medicare program makes the only exception to this rule. They will pay for the collection of a Pap smear specimen when that specimen is collected at the time of a non-covered evaluation and management service. If Medicare reimburses the physician for the E/M service, the collection fee will not be reimbursed.
Interpretation of Pap Smear
The physician or laboratory that performs the official interpretation and prepares the signed written report normally bills the Pap smear interpretation. That is, only one physician/lab gets to bill for the interpretation. If the slide is sent to a laboratory and they bill the patient/insurer for the interpretation, the physician who ordered the Pap smear cannot bill for the interpretation also.
The review of the laboratory report is an element of medical decision-making. The physicians office may elect to bill for the service on behalf of the laboratory. In that case, the office bills the CPT laboratory code (s) that describe the type of Pap smear test performed, and adds a modifier 90 to these codes to indicate that they did not perform the interpretation. If the physician who orders the Pap smear has an office laboratory that is qualified under CLIA regulations to perform this level of test, the laboratory codes may be billed without the modifier 90, but the CLIA number would need to be included on the claim form.
The note in CPT that says physicians can bill for interpretation of the results of diagnostic test/studies using the modifier 26 does not mean that the physician gets to bill for a confirmatory interpretation. That is, the physician who is billing for interpretation must be the one who is responsible for the official written report.
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