Understand how to process coding for someone with an abnormal Pap smear who needs a repeat test
A: The answer to this question depends on whether the patient is covered under Medicare or commercial insurance.
According to the Centers for Medicare and Medicaid Services' Medicare National Coverage Determinations Manual, effective June 19, 2006, Medicare pays for a Pap smear for women of childbearing age every two years. If the patient is at high risk of developing cervical cancer, Medicare allows more frequent screening. Factors determining high risk for cervical and vaginal cancer:
When lab personnel can't read a Pap smear because the sample doesn't contain enough cells, the provider performs a repeat screening Pap smear. The Medicare Claims Processing Manual (Chapter 18, 30.6.5) says that the provider should report these repeat screenings using Q0091 with modifier –76 (repeat procedure or service by the same physician) appended. Diagnosis code 795.08 (unsatisfactory smear/inadequate sample) should be linked for explanation.
Billing preventive services to Medicare may be complex but involves only one set of guidelines. Billing non-Medicare payers for the same services is more convoluted, however, because no single policy or set of guidelines is followed. Depending on the payer and the service(s) provided, you may have to:
To understand each private-payer policy, contact the payer directly and ask for the information in writing. Commonly, however, the payer will require that a Pap smear and pelvic/breast exam be billed one of the following ways:
Regarding diagnosis codes, the guidelines for private payers are similar to those for Medicare, except for the comprehensive preventive exam, which Medicare doesn't cover. Link code V70.0 (routine general medical examination at a healthcare facility; health checkup) with preventive care codes 9938x and 9939x.
In comparison, for the first pelvic/breast examinations (with or without Pap smear), use V72.31 (routine gynecological examination). For a screening Pap smear alone, use V76.2 (routine cervical Pap smear). The second and third Pap smears should be billed the same as they are to Medicare, with the evaluation/management code linked to the diagnosis code that substantiates medical necessity.
The author is a compliance manager for Baptist Medical Associates in Louisville, Kentucky. Have a coding or managed care question for our experts? Send it to email@example.com