Updated Edits for Screening Pap Smears (Q0091)

Medicare pays for one Pap smear every year for high risk beneficiaries and one Pap smear every two years for low risk beneficiaries. Currently, Medicare does not edit to see if a low risk Pap Screen has been paid when processing a high risk Pap Screen for the same patient. Beginning for dates of service on and after July 01, 2005, these types of claims will deny appropriately.

In instances where unsatisfactory screening Pap smear specimens have been collected and sent to the clinical laboratory and the clinical laboratory is unable to interpret the test results, another specimen is needed. When billing for sending another specimen to the clinical laboratory, the physicians should use HCPCS code Q0091 along with modifier 76, which will bypass the frequency editing and allow payment to be made for reconveyance of the specimen.

Effective for services rendered on and after July 01, 2005, where physicians must perform a screening Pap smear that they know will not be covered by Medicare because the low risk beneficiary has already received a covered screening Pap smear in the past two years, the physicians should obtain an ABN and can bill using Q0091-GA to receive the appropriate denial.

V72.31 will be added to the edits in the Medicare system for low risk beneficiaries. The V72.31 diagnosis code is to be used on Pap smear claims to indicate the beneficiary is a low risk patient, but only when a full gynecological examination is performed.

The following chart lists the diagnosis codes that Medicare recognizes for low risk or high risk patients for screening Pap smear services with V72.31 recognized as of July 01, 2005.

Low Risk Diagnosis Codes Definitions

• V76.2 Special screening for malignant neoplasms, cervix
• V76.47 Special screening for malignant neoplasm, vagina
• V76.49 Special screening for malignant neoplasm, other sites. Note: providers use this diagnosis for women without a cervix.
• V72.31 Routine gynecological examination. Note: This diagnosis should only be used when the provider performs a full gynecological examination.

High Risk Diagnosis Code

• V15.89 Other