Changes in Medicare policy have affected how we need to code and bill Medicare for Pap Smears. Medicare now differentiates between a screening and diagnostic Pap smear codes. Therefore, effective immediately, you must now record on all requisitions whether a Pap Smear is for diagnostic or screening purposes. This distinction must be identified on all requisitions because there are limitations on the frequency with which screening Pap Smears are allowed for payment. In order to maximize reimbursement, we must code as accurately as possible.
To help you determine if a Pap Smear is for diagnostic or screening purposes, Medicare has provided the following guide:
Diagnostic Pap Smears are ordered when there are signs/symptoms of disease. For Diagnostic (non-screening) Pap Smears select the appropriate ICD-9 code based on the reason the test was performed. In order to be reimbursed, a diagnostic Pap Smear must meet any of the following criteria:
- The patient is being treated or has been treated for cancer of the cervix, uterus, or vagina
- The patient has had a previous abnormal Pap Smear
- During the physical exam, the physician found abnormalities of the vagina, cervix, uterus, ovaries, or adnexa
- The patient exhibits signs or symptoms that might, in the physician’s judgement, reasonably be related to a gynecological disorder
Screening Pap smears are covered when ordered and collected by a physician (or other authorized practitioner). Patients for screening Pap smears fall into two risk categories; no-risk and at-risk patients. A no-risk patient (ICD-9 code V76.2) is eligible for routine screening once every two years. However an at-risk patient (ICD-9 code V15.89) may receive a pap smear on an annual basis. The criteria for an annual screening Pap smear may include one of the following conditions:
- The physician recommends the procedure
- The patient is of childbearing age
- The patient has not had a Pap smear in the past 3 years
- Other high risk factors for cervical/vaginal cancer
Medicare defined High Risk Factors:
- Early onset of sexual activity (under age 16)
- Multiple sexual partners (more than 5 in a lifetime)
- History of sexually transmitted disease
- Fewer than 3 negative Pap Smears within the last 7 years
- Daughters of women who took DES during pregnancy.
Failure to comply will result with the Pap Smear and requisition being returned to you for this critical information. Charges for both screening and diagnostic Pap Smears will remain identical. Please replace old Cytopathology requisitions (MHO1585) with the newest version dated 12/00. You must record on all requisitions whether a Pap Smear is for diagnostic or screening purposes.
Questions or comments regarding this change can be directed to: Chris Jensen, M.D., at 356-3217 or Elizabeth Goetzman at 356-3383. Additional information can be found at the following web site: http://www.hcfa.gov/pubforms/transmit/ab987160.htm.
Thank you for your cooperation in this matter.