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Reimbursement Advisor


Insurer won’t pay for routine lab tests

May 2005 · Vol. 17, No. 5

<huc>Q</huc> When we bill for Pap tests (Q0091), vaginal cultures (87070), and stool guaiac (82270), insurance companies refuse to pay.

They tell me we can collect for obtaining the specimen, but I cannot find the correct CPT codes. How should I proceed?

<huc>A</huc> It depends on what payer you are billing and whether you have the correct Clinical Laboratories Improvement Act (CLIA) certificate to bill for laboratory procedures.

The code Q0091 was developed by Medicare to reimburse physicians for collecting a Pap smear at the time of an otherwise noncovered service. When they later added the code G0101 for the pelvic and breast exam portion of a preventive visit, they continued to reimburse for the collection as well.

Collection Codes

This collection code is not recognized by all payers, however. In fact, the American College of Obstetricians and Gynecologists (ACOG) has indicated that collection is part of the exam and not a separately billable service. However, some payers will allow you to collect for handling the specimen by using the code 99000.

Lab Codes

As for the lab tests you are billing, all providers are required to have the proper certificate before they can bill for laboratory tests. By billing the lab codes, you are telling the payer you are qualified to perform these tests and that you did, in fact, perform them. Once again, there is no collection code for either of these tests. Code 82270, which is a waived test, can be performed by the physician in the office, and the collection of the stool specimen is an integral part of the code. A waived test, by the way, still requires a certificate (visit www.cms.hhs.gov/clia/certypes.asp for definitions of the various certificate levels).

Culture Codes

The culture code you are using, 87070, is considered a highly complex test for which the highest certificate level would be required. Again, there is no collection code for the vaginal specimen, but you might be able to bill 99000 for the handling. If the Pap smear and culture collection are performed at the same visit, you would only bill 99000 once.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

OBG Management ©2005 Dowden Health Media
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