There are specific guidelines to follow when coding and billing Medicare for a Pap smear and pelvic exam. Physicians ask quite frequently if it’s acceptable to bill a pelvic exam with a Pap smear when only a breast exam was performed. The answer to that question is no; but let’s go over the rules so that you have a better understanding of the coding and billing process.

Medical Coding and Billing for Pap Smear and Pelvic Exams

First of all, Medicare covers a screening Pap smear once every two years. That means that at least twenty-three months must have passed following the month during which the patient received her last covered Pap smear.

A screening Pap smear is provided for early detection of cervical or vaginal cancer. If the woman is considered high risk, a physician can recommend that the Pap be done more often than two years. There would have to be evidence from the medical history or other findings that the patient is of childbearing age and has had an exam that indicated the presence of cervical or vaginal abnormalities; and at least eleven months have passed following the month that the last Pap was performed. The other factor would be that the patient is at high risk of developing cervical or vaginal cancer and at least eleven months have passed following the month that the last covered screening Pap was performed.

What is considered a high risk patient?
1. Multiple sexual partners (five or more in a lifetime)
2. Early onset of sexual activity (under sixteen years of age)
3. History of a sexually transmitted disease (including HIV infection)
4. Fewer than three negative or any Pap smears within the previous seven years
5. DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy.

HCPCs code Q0091 is defined as a screening Papanicolaou smear, obtaining, preparing, and conveyance of cervical or vaginal smear to the laboratory.

Diagnosis codes used for a Pap are V76.2 for asymptomatic low risk patients, which is a special screening for malignant neoplasm of the cervix, V76.49 is used for patients who no longer have a uterus or cervix and code V76.47 is used for a special screening for malignant neoplasm of the vagina. A routine gynecological exam code is V72.31 and for high risk patients or women who have specified personal history presenting hazards to their health, use V15.89.

There are eleven elements that are associated with a screening pelvic exam. In order to use code G0101 for the screening pelvic, a physician must include at least seven of the eleven elements listed below:
1. External Genitalia
2. Urethral Meatus
3. Urethra
4. Bladder
5. Vagina
6. Cervix
7. Uterus
8. Adnexa
9. Anus and Perineum
10. Digital Rectal Exam
11. Inspection and Palpation of the Breasts
The covered diagnosis codes are the same as those listed above for the screening Pap: V76.2, V76.47, V76.49, V15.89 and V72.31.

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