How do I bill for a PAP smear?

April 22nd, 2009 - Codapedia Editor
Categories:   Coding   Preventive Medicine Service  
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Physicians often ask what codes to use in order to bill for a pap smear provided during a preventive medicine service or other E/M service.  The only CPT® codes  for pap smears are for Pathologists, for the physician interpretation of the cytology specimen.

So, what does the GYN or primary care physician use for doing the physical exam and taking the specimen?  It depends on the nature of the visit.

If the service is a screening service, that is, part of an annual exam or preventive medicine service, then there is no additional code to bill (unless the patient is a Medicare patient.  See below.)  The preventive medicine codes include an age/gender appropriate history and exam, along with anticipatory guidance, risk factor reduction and referral for or provision of immunization and other screening diagnostic tests appropriate for that patient's age, gender and medical history.   That is, if the woman's age requires a pelvic and pap smear, those services are part of the payment for the preventive medicine service.  There is no additional payment.  And, you are not paid less for not doing it, if it is not required. 

Medicare does not pay for "routine" services.  Congress, from time to time, adds screening benefits for Medicare beneficiaries.  One of the benefits they added was a screening pelvic and breast exam, and pap smear.  (There are other articles in Codapedia about these services.)  Because Medicare does not pay for routine, preventive care, CMS developed a CPT® code to carve out and describe the covered preventive medicine service, (the screening pelvic and breast exam, G0101) and obtaining the pap smear. (Q0091).  These services are used for screening within the frequency limits developed by CMS.

Many commercial insurance companies do pay for Q0091, obtaining and preparing the pap smear.  They do not pay for 99000, lab handling.

For patients who need diagnostic pap smears, there is no CPT® or HCPCS code to describe only a pelvic exam or obtaining (specifically) the pap smear.  It is not correct to use Q0091 for repeat pap smears due to medical problems.  The payment for the exam is included in the E/M service provided that day.  Select the level of service based on the level of history, exam and MDM provided and documented.

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