Clinical office notes:

1. pelvic exam with classical/routine Pap test sampling: a device is used to generally obtain a cervix sample during a pelvic exam to include speculum insertion to see & sample the cervix¹¹: 

   A routine pelvic exam done in the screening mode...in the absence of any signs (such as vaginal discharge), symptoms (such as pelvic pain), diagnostic setting (having abnormal Pap smears),  or established illness (treating and follow-up management of cervical dysplasia)......should be coded  using a well-visit service code (preventive medicine codes 99381-99397) and a clinical diagnosis "v" code of v72.31¹⁷ (Pap taken as periodic/annual exam); and, should a smear have been abnormal in the past, became subsequently normal & patient is now back into the exam  mode of periodic/annual exams to again confirm normalcy, use v72.32¹⁷ . 

   According to CPT and Medicare, the exam of a patient presenting to the office with a problem or problematic setting (as noted above)...in the diagnostic mode...should be coded using the appropriate evaluation and management (E/M) office visit code (99201-99215). The pelvic exam would be considered part of the medical exam portion of the office visit; an appropriate diagnosis code (s)  would be used.

   HCFA Common Procedure Coding System (HCPCS) code G0101, "Cervical or vaginal cancer screening; pelvic and clinical breast exam," is intended to be used with Medicare patients to whom such a service is provided, since it is a covered Medicare benefit and preventive medicine services are not. You may use G0101 (clinicians pelvic exam resulting in a Pap test) with another E/M code if the E/M service is provided at the same encounter for different reasons; you'll also need to use a -25 modifier. And, Q0091, screening Pap (for clinical office role obtaining, preparing, and conveying Pap sample to a lab). 

2. pelvic exam with directed Pap test sampling: speculoscopy with dilute vinegar and a blue light to show white areas so that the Pap sample can be taken with specific & direct attention to the white areas (if any be revealed). A disposable system is PapSure. CPT 2003 uses code 0031T for the blue-light clinical exam & 0032T for the clinically directed collection. [I suppose that conventional or liquid-based sampling devices employed in a very specifically directed fashion, as above, could use this same code (though it would be wise to check with a major carrier or two).] 

Lab/pathology claims filing notes: Pap lab "category"...screening (low vs. high risk) vs. diagnostic...and insurance coverage: Many insurers cover the screening category Pap apart from any issue of the policy annual deductible. But the charge for a diagnostic category Pap may have to be applied to the deductible. Regardless of any known or knowable case/patient history (such as "previous atypical Pap"), findings, or complaints, only the ordering professional knows whether their case analysis caused them to obtain a Pap sample for a (1) screening category reason or a (2) diagnostic category reason. That is, whether certain facts warrant "high-risk, screening" vs. "diagnostic" are a clinical opinion (not a lab or lab billing company opinion) related to the specifics of each case.   Be aware that some insurers deny a claim for 88141 (1) because they use claims review software that says that 88141 is a denied claim because the service is "bundled"...especially if it is a "screening Pap case"...with other Pap smear codes (not so)...(there are major lawsuits pending about this and other tactics to avoid coverage in good faith). And, being a relatively new code, 88141 (pathologist's diagnostic case review & rendering of an abnormal diagnosis upon which your doctor will act) is often not only denied by the insurer but counted as a contractually non-allowed service (which is adjusted off and the pathologist is not allowed to balance bill the patient for this crucial service which has already been performed in good faith)...an unfair business practice. 88174 & 88175 re-imbursement by BC-BS of S. C.: Dr. Jordan assures that these qualify for payment and should have been, and should be, paid about equally¹⁴.

1. -GA means the provider expects payment to be denied by Medicare as "not reasonable & necessary" AND that an advance beneficiary notice (ABN) was signed by the patient. 
2. -GZ same as -GA but without a signed ABN. 
3. -GY means that the service is either not a Medicare benefit or is a statutorily uncovered service (such as screening tests).

SCREENING Paps ICD9 office submitting diagnosis "v" codes:

• v76.2 (low-risk screen) has a cervix & thought clinically to be a low-risk patient; [or has had hysterectomy,  v76.49⁴; but, that "v" code won't work⁵ until 1 Oct. 2003¹⁵]; as 10/1/03, v76.47 "special screening for malignant neoplasm, vagina [post hyst. or no cervix¹⁵]" and v76.49 "special screening for malignant neoplasm, other sites [than cervix] patient does not have a cervix¹³...may need to check with carrier to see whether they require v76.47 or v76.49 when cervix is absent¹⁵.
• v15.89 (high-risk screen) thought clinically to be a high risk patient^{10, 12} because of [Medicare and many other carriers only cover screening Paps in the high-risk "v" code group]:
  1. early-age onset of sexual activity (before age 16)
  2. has had multiple sexual partners (five or more in lifetime)
  3. history of any sexually transmitted disease...STD (including HIV)
  4. has had fewer than 3 negative Paps in past 3 years (if premenopausal) or no Pap test within prior seven years [note: a history of atypical Pap more remotely than within the 3 prior years may just be considered a high-risk screening category.]
  5. is a daughter of a mother prescribed DES during her pregnancy with this daughter
• Pathologist Pap diagnosis code: normal is v71.8; abnormals

2nd Patient Category...Diagnostic Pap Smear:

"Diagnostic" defined: Medicare and other payers cover diagnostic Pap smears...patients with signs or symptoms leading the provider to obtain the Pap sample⁵...under the following conditions, which conditions define "diagnostic". Did you tell your doctor? Presence of any of the following list items in your case does not obligate that your case be categorized as "diagnostic".  This includes post-treatment diagnostic follow-up Pap tests to diagnostically check the current status of that underlying diagnosis. After considering all of your information, only your ordering professional knows whether your case ought to be  categorized as "diagnostic"...the mode, frame of mind, or reason he/she obtained the test being for diagnosis of the cause of the signs/symptoms:

• Previous cancer of the cervix (v10.41), uterus (v10.42) or vagina (v10.44) that has been or is presently being treated
• Previous abnormal Pap smear (at any time in the past)
• Any abnormal findings of the vagina, cervix, uterus, ovaries or pelvic adnexae
• Any significant complaint by the patient related to female reproductive system
• Any signs or symptoms that might, in the physician’s judgment, reasonably be related to a gynecological disorder (submit the appropriate ICD-9 code to report the sign or symptom)

If organisms are found: the following codes can be added...HPV koilocytosis, 079.4; herpes, 054.19; candida, 112.2; trichomonas, 131.09. 

[back to initial page on insurance matters] References:

1. Pathology/Lab Coding Alert, 2(6):41-48, June 2001
2. College of American Pathologists web site
3. CMS program memorandum B-01-58, Sept. 25, 2001.
4. update, Medicare Carriers Manual, part 3, transmittal 1675, sect. 4603.2 C,  31 Aug. 2000. "There are a number of appropriate diagnosis codes that can be listed in Item 21 of the HCFA 1500 claim form for Pap smear or pelvic exam claims in addition to v76.2 0r v76.49 (for low-risk patients)...However, one of the diagnosis codes in Item 21 for low-risk beneficiaries [patients] must be v76.2 or v76.49, and this is the diagnosis code that must be pointed to in Item 24E of the HCFA 1500."
5. Pathology/Lab Coding Alert 3(5):33-36, May 2002 [but, v76.49 won't work]
6. Jim Pollard, Director Payor Relations, TriPath Imaging office, e-mail advice of 24 October 2002.
7. Jim Pollard, Director Payor Relations, TriPath Imaging office, e-mail advice (PapNet rescreening on liquid-based preps never FDA approved) of 28 October 2002.
8. Jim Pollard, Director Payor Relations, TriPath Imaging office, e-mail advice of 22 November 2002 (noting new CMS "final payment determinations and codes"...effective 1/1/2003).
9. Pathology/Lab Coding Alert 3(12):93, Dec 2002 
10. Pathology/Lab Coding Alert 3(5):33-34, May 2002
11. Am. Acad. Family Physicians web site March 2000, Kent J. Moore. 
12. Georgia Medicare Part B, Government Benefit Administrators website
13. PSA Coding & Compliance Alert, June 2003.
14. per 24 July 2003 phone call from PSA chair, Dr. Ed Catalano, relaying info from his (and Jim Pollard & Bama Saltzman) meeting with BC-BS medical director, Dr. Ashby Jordan on 23 July 2003.
15. Pathology/Lab Coding Alert 4(7):53-54, July 2003.
16. ICD-9-CM Diagnosis and CPT/HCPCS Coding Rules for Screening and Diagnostic Pap Smears for Medicare Beneficiaries, updated 1 January 2003.
17. "5th digit" requirement now by at least Medicare (PSA e-mail 14 Oct. 2004).
18. CAP Today, Billing and Coding in Cytopathology: Deciphering the Alphanumeric Soup, [using CPT 2005 & ICD-9 2005] June 2005. [CAP Today].
19. Pam Matthews, coder with our account @ PSA, 10,17/05 response to SH.
20. On-line ICD9 coding resource by Chris Endres

(posted Oct. 2001; latest update 18 October 2005)