(Medicare Claims Processing Manual)

Effective for claims with dates of service on or after July 9, 2015, payment may be made for HCPCS G0476 (cervical cancer screening, all -inclusive HPV co -test with cytology (Pap smear) to detect HPV DNA or RNA sequences) only when submitted with a Place of  Service Code equal to 81, Independent Lab or 11, Office.   A.  Screening Pap Smears: A/B MAC (B)  Action for Submitting Claims to the Common Working File (CWF) and CWF Edit   When a A/B MAC (B) receives a claim for a screening Pap smear, performed on or after January 1, 1998, it must enter a deductible indicator of 1 (not subject to deductible) in field 67 of the HUBC record.   CWF will edit for screening pelvic examinations performed more frequently than allowed according to the presence of high risk factors.   30.3 - Deductible and Coinsurance  (Rev. 1, 10- 01-03)  B3-4603.4, A3- 3628.1.A.3  Neither the Part B deductible nor coinsurance apply for services paid under the laboratory fee schedule.  The Part B deductible for screening Pap smear and services paid for under the physician fee schedule is waived effective January 1, 1998.  Coinsurance  applies.   A. A/B MAC (B)  Action for Submitting Claim to CWF and CWF Edit   B3-4603.4, B3- 4603.6, B3- 4603.1.B   When a A/B MAC (B) receives a claim for a screening Pap smear, performed on or after January 1, 1998, it must enter a deductible indicator of 1 (not subject to deductible) in field 67 of the HUBC record.   CWF will edit for screening pelvic examinations performed more frequently than allowed according to the presence of high risk factors.   30.4 - Payment Method  (Rev. 1, 10- 01-03)  B3-4603.1.C.1 and 2 Payment may be under the clinical diagnostic lab fee schedule or the MPFS, depending upon the code billed.  See the categories in 30.5 of this chapter for a description.  30.4.1 - Payment Method for RHCs and FQHCs (Rev. 795, Issued:  12- 30-05; Effective:  10 -01-04; Implementation: 04 -03-06)  The professional component of a screening Pap smear furnished within an RHC/FQHC by a physician or non physician is considered an RHC/FQHC service.  RHCs and FQHCs bill the A/B MAC (A) under bill type 71X or 73X for the professional component along with re venue code 052X.  See Chapter 9, for RHC and FQHC bill processing instructions.  The technical component of a screening Pap smear is outside the scope of the RHC/FQHC benefit.  If the technical component of this service is furnished within an independent RHC or freestanding FQHC, the provider of that technical service bills the A/B MAC  (B) on Form CMS -1500.   If the technical component of a screening Pap smear is furnished within a provider -based RHC/FQHC, the provider of that service bills the A/B MAC (A) under bill type 13X, 14X, 22X, 23X, or 85X as appropriate using their outpatient provider number (not the RHC/FQHC provider number since these services are not covered as RHC/FQHC services).  The appropriate revenue code is 311.  Effective 4/1/06, type of bill 14X is for non- patient laboratory spec imens.   30.5 - Screening Pap Smears: Healthcare Common Procedure Coding System (HCPCS) Codes for Billing  (Rev. 3460, Issued: 02- 05-16, Effective: 07 -09-16, Implementation: 03- 07-16 - for non -shared MAC edits; 07 -05-16 - CWF analysis and design; 10- 03-16 - CWF Coding, Testing and Implementation, MCS, and FISS Implementation; 01 -03-17 - Requirement BR9434.04.8.2)   The following HCPCS codes can be used for screening Pap smear:   A.  Screening Pap Smears: Codes Billed to the A/B MAC (B) and Paid Under the Medicare Physician Fee Schedule (MPFS)   The following HCPCS codes are submitted by those providers/entities that submit claims to A/B MACs (B).  The deductible is waived for these services effective January 1, 1998, however, coinsurance applies.   NOTE :  These codes are not billed on A MAC claims except for HCPCS Q0091 which may be submitted to A/B MACs (B).  Payment for HCPCS Q0091 performed in a hospital outpatient department is under the outpatient prospective payment system (OPPS) (see 30.5C).   Q0091 -  Screening Papanicolaou (Pap) smear, obtaining, preparing and conveyance of cervical or vaginal smear to laboratory;    P3001 -  Screening Papanicolaou smear, cervical or vaginal, up to three smears requiring interpretation by a physician;    G0124 -  Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician; and   G0141 -  Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual re -screening, requiring interpretation by physician.   B.  Screening Pap Smears: Codes Paid Under the Clinical Lab Fee Schedule by A/B MACs   The following codes are billed to A/B MACs (A) by providers they serve, or billed to A/B MACs (B) by the physicians/suppliers they service.  Deductible and coinsurance do not apply.   P3000 -  Screening Papanicolaou smear, cervical or vaginal, up to three smears, by a technician under the physician supervision;    G0123 -  Screening cytopathology, cervical or vaginal (any reporting system) collected in preservative fluid; automated thin layer preparation, screening by cytotechnologist under physician supervision;    G0143 -  Screening cytopathology, cervical or vaginal, (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and re -screening, by cytotechnologist under physician supervision;    G0144 -  Screening cytopathology, cervical or vaginal, (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system under physician supervision;    G0145 -  Screening cytopathology, cervical or vaginal, (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual re -screening under physician supervision;    G0147 -  Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision; and   G0148 -  Screening cytopathology smears, cervical or vaginal, performed by automated system with manual reevaluation.   C.  Screening Pap Smears: Payment of Q0091 When Billed to A/B MACs (B)   Payment for HCPCS Q0091 in a hospital outpatient department is under OPPS.  A skilled nursing facility (SNF) is paid using the technical component of the MPFS.  For a critical access hospital (CAH), payment is on a reasonable cost basis.  For rural health clinics/Federally qualified health centers (RHC/FQHCs) payment is made under the all -inclusive rate for the professional component.  Deductible is not applicable, however, coinsurance applies.   The technical component of a screening Pap smear is outside the RHC/FQHC benefit.  If the technical component of a screening Pap smear is furnished within a provider -based RHC/FQHC, the provider of that service bills the A MAC under type of bill (TOB) 13X,  14X, 22X, 23X, or 85X as appropriate using their base provider number (not the RHC/FQHC provider number since these services are not covered as RHC/FQHC services).  For independent RHCs/FQHCs, the practitioner bills the technical component to the A/B MACs (B) on Form CMS -1500 or the ANSI X12N 837 P.  Effective April 1, 2006, TOB 14X is for non- patient laboratory specimens.  D.  Screening Pap Smears: Payment of HCPCS Q0091 When Billed to A/B MACs (B)   Payment for HCPCS Q0091 is paid under the MPFS. Deductible is not applicable, however the coinsurance applies.   Effective for claims with dates of service on and after July 1, 2005, on those occasions when physicians must perform a screening Pap smear (HCPCS Q0091) that they know will not be covered by Medicare because the low -risk patient has already received a cov ered Pap smear (HCPCS Q0091) in the past 2 years, the physician can bill HCPCS Q0091 and the claim will be denied appropriately.  The physician shall obtain an advance beneficiary notice (ABN) in these situations as the denial will be considered a not reas onable and necessary denial.  The physician indicates on the claim that an ABN has been obtained by using the GA modifier.   Effective for claims with dates of service on or after April 1, 1999, a covered evaluation and management (E/M) visit and HCPCS Q0091 may be reported by the same physician for the same date of service if the E/M visit is for a separately identifiable servi ce.  In this case, the modifier -25 must be reported with the E/M service and the medical records must clearly document the E/M reported.  Both procedure codes should be shown as separate line items on the claim.  These services can also be performed sep arately on separate office visits.   E.  Screening Pap Smears: CWF Editing for HCPCS Q0091  The CWF will edit for claims containing HCPCS Q0091 effective for dates of service on and after July 1, 2005.  Previously, the editing for HCPCS Q0091 had been removed from the CWF.  Medicare pays for a screening Pap smear every 2 years for low -risk patien ts based on the low -risk diagnoses, see sections 30.2 and 30.6.  Medicare pays for a screening Pap smear every year for a high- risk patient based on the high- risk diagnosis, see sections 30.1 and 30.6.  This criteria will be the CWF parameters for editing HCPCS Q0091.   In those situations where unsatisfactory screening Pap smear specimens have been collected and conveyed to clinical labs that are unable to interpret the test results, another specimen will have to be collected.  When the physician bills for this reconveya nce, the physician should annotate the claim with HCPCS Q0091 along with modifier - 76, (repeat procedure by same physician).   30.6 - Screening Pap Smears: Diagnoses Codes  (Rev. 11445, Issued:06- 03-22 Effective:05 -09-22, Implmentation:05- 09-22)  Effective October 1, 2015 the below are the current diagnoses that should be used when billing for screening Pap smear services   The following chart lists the diagnosis codes that CWF must recognize for high- risk patients for every year screening Pap smear services.   ICD- 10-CM Codes for PAP High Risk every year   ICD- 10 CM code   Definitions  Z77.29  Contact with and (suspected) exposure to other hazardous substances  Z72.51  High risk heterosexual behavior  Z72.52  High risk homosexual behavior    Z72.53  High risk bisexual behavior  Z77.9  Other contact with and (suspected) exposures hazardous to health  Z91.89  Other specified personal risk factors, not elsewhere classified  Z92.850  Personal history of Chimeric Antigen Receptor T -cell therapy  Z92.858  Personal history of other cellular therapy  Z92.86  Personal history of gene therapy  Z92.89  Personal history of other medical treatment    The following chart lists the diagnosis codes that CWF must recognize for low -risk for every 2 years    ICD- 10-CM Codes for PAP Low Risk every 2 years    ICD-10 CM code   Definitions  Z01.411  Encounter for gynecological examination (general) (routine) with abnormal findings  Z01.419  Encounter for gynecological examination (general) (routine) without abnormal findings  Z12.4  Encounter for screening for malignant neoplasm of cervix  Z12.72  Encounter for screening for malignant neoplasm of vagina  Z12.79  Encounter for screening for malignant neoplasm of other genitourinary organs  Z12.89  Encounter for screening for malignant neoplasm of other sites     A.  Screening Pap Smears: Applicable Diagnoses for Billing A/B MAC (B)