The following diagnoses/conditions are those justifying payment for pap smears. (This is not intended to be an all-inclusive list.)

Abnormal vaginal discharge: 131.00
Cervical ulcerations: 622.0
Cervicitis: 016.7,616.0
Condyloma: 078.10-078.11, 091.3
Endometriosis: 617
Fibroma of cervix: 219.0
Follow up to previous or suspicious pap smear: 622.1, 795.00, 795.01, 795.02, 795.09, V10.40-V10.44
Menopausal syndrome: 627
Neoplastic disease: 218-221, 236.0-236.3, 616.8-616.9, 621.8, 654.10-654.14, 789.3
Pelvic malignancy: 158.8, 179-184, 195.3, 197.6, 198.6, 198.82, 233.1-233.3
Polyps or cysts, cervical or uterine: 616, 620.0-620.2, 620.8, 621.0, 621.8, 622.7-622.8, 654.60-654.64, 752.11, 752.41
Post-menopausal bleeding: 627.1
Pregnancy: 630-638, 640-676, V22, V23-V23.5, V23.8-V23.9
Vaginal bleeding of unknown origin (abnormal): 626.2, 626.6-626.9
Vaginal or vulvar lesions, any type: 221.2, 616.2, 623.0, 623.7-623.8, 624.6, 624.8, 654.8
Vaginitis, any type: 054.11, 098.0, 112.1, 131.00-131.01, 616.1, 627.3
Vulvitis and vulvovaginitis: 054.11, 098.2, 131.01, 616.1, 616.5
Women exposed to DES (Diethylstilbestrol) prior to birth

Payment may be made for pap smears performed to "rule out" a suspected condition that may be the cause of the patient's symptoms.

Cyto-hormonal study (88155) is used primarily to determine the need for, or possible response to, estrogen therapy and to evaluate the hormonal status in patients who have certain types of endocrine problems (e.g., failure to ovulate, possible abnormal sexual development, infertility, etc.) Payment may be made for the cyto-hormonal study (88155) in addition to the pap smear (88142-88145, 88150-88154, 88164-88167).

Claims for pap smears with diagnoses/conditions other than those listed above should be denied on the basis of medical necessity. Individual consideration can be given if this decision is questioned.

Pap smears using the ThinPrep method of slide preparation are eligible for payment under codes 88142, 88143, G0123, G0124, G0143, as appropriate.

Pap smears supplemented with the PapNet or AutoPap computerized rescreening are eligible for payment under codes 88144, 88145, 88152, 88154, 88166, 88167, G0144, G0145, as appropriate.

Pap smear screening by automated systems (88147, 88148, G0141, G0147, G0148) do not involve manual intervention by a technician. The screening is performed totally by the equipment. These pap smears are considered investigational/experimental and not eligible for payment. Scientific evidence does not demonstrate the reliability of the use of automated systems as primary screening tools.

When reported, payment may be made for the physician interpretation (code 88141) in addition to the pap smear codes (88142-88145, 88150-88154, 88164-88167, G0123, G0124, G0143, G0144, G0145, P3000, P3001). The physician interpretation of an investigational/experimental pap smear (G0141, G0147, G0148, 88147, 88148) is considered investigational/experimental and therefore, not eligible for payment.

When a provider obtains a specimen for a pap smear, then refers that specimen to a laboratory for examination, the cost of obtaining the specimen is included in the allowance for the gynecological examination or evaluation and management service. Payment should be made to the laboratory for the actual pap smear examination.

However, if there is a billing arrangement whereby the provider reimburses the laboratory for the pap smear examination, payment can be made to the provider for the pap smear. No payment should be made to the laboratory in this case.

See Medical Policy Bulletin V-35 for guidelines on routine/screening pap smears.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

PRN References

02/1998, New pap smear reporting adopted