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Reimbursement Advisor

Screening after abnormal Pap: ‘Problem, not preventive’

April 2004 · Vol. 16, No. 4

<huc>Q</huc> One frustrating problem we frequently encounter is when the doctor wants a patient with a recent abnormal Pap to return every 6 months for repeat cytology.

Payers do not recognize Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) with the appropriate evaluation/management (E/M) code and with 795.0X (abnormal Pap smear) as the diagnosis. Because a Pap is not a routine procedure with our E/M visits, we typically bill out the Q0091 code.

A follow-up abnormal Pap is a problem—not a preventive—E/M service. Collection is part of the exam and not coded separately.

One insurance company told me I should use laboratory codes 88142-88150. Any advice?

<huc>A</huc> The American College of Obstetricians and Gynecologists (ACOG) takes the position that specimen collection at the time of the pelvic exam should not be billed separately—but Q0091, a Healthcare Common Procedure Coding System (HCPCS) code, was created by Medicare for use with Medicare patients.

It was developed in a time when Medicare did not cover annual preventive gynecologic examinations, but did pay laboratories for interpreting cervical smears collected at these preventive visits. Medicare wanted to give physicians some reimbursement for their time spent collecting the specimen. In 1998 Medicare began covering pelvic and breast exams, but continued to pay for specimen collection for screening Pap smears.

A follow-up abnormal Pap, however, is billed as a problem—not a preventive—E/M service. In this case, Medicare agrees with ACOG that the collection is part of the exam and not coded separately.

Many private payers have also adopted this view—even those that formerly reimbursed a small fee for collection with code 99000 (handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory).

Under no circumstance should a laboratory code be billed for collecting the specimen.

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