(Medicare Claims Processing Manual)

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)   There are a number of appropriate diagnosis codes that can be used in billing for screening Pap smear services that the provider can list on the claim to give a true picture of the patients condition.  Those diagnoses can be listed in Item 21 of Form CMS -1500 or the electronic equivalent (see Chapter 26 for electronic equivalent formats).  In addition, one of the following diagnoses shall appear on the claim: the low -risk diagnosis of Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.89 or the high- risk dia gnosis of, Z77.29, Z72.51, Z72.52, Z72.53, Z77.9, Z91.89, Z92.850, Z92.858, Z92.86, and Z92.89. (Effective Oct 1, 2015) One of the above diagnoses must be listed in item 21of the Form CMS -1500 or the electronic equivalent to indicate either low risk or high risk depending on the patients condition.  Then either the low -risk or high- risk diagnosis must also be pointed to in Item 24E of Form CMS -1500 or the electronic equivalent.  Providers must make sure that for screening Pap smears for a high- risk benefic iary that the high -risk diagnosis code appears in Item 21 that must be pointed to in Item 24E or the electronic equivalent.  If Pap smear claims do not point to one of these specific diagnoses in Item 24E or the electronic equivalent, the claim will reject in the CWF.  Periodically, A/B MACs (B) should do provider education on diagnosis coding of Pap smear claims.   B.  Screening Pap Smears: Applicable Diagnoses for Billing A/B MACs (A)   Providers report one of the following diagnosis codes in Form CMS -1450 or the electronic equivalent ( NOTE:  Information regarding the form locator numbers that correspond to the diagnosis codes and a table to crosswalk its CMS -1450 form locator to the 837 transaction is found in Chapter 25.):   Low -risk ICD -10-diagnosis codes for every 2 years:     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    High -risk ICD -10 diagnosis codes for 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    Periodically provider education should be done on diagnosis coding of Pap smear claims.   C.  HPV Screening: Applicable Diagnoses for Billing A/B MAC (A/B)   Effective for claims with dates of service on or after July 9, 2015, providers shall report the following diagnosis codes when submitting claims for HCPCS G0476 -  Cervical cancer screening, all-inclusive HPV co -test with cytology (Pap smear) to detect HPV DNA or RNA sequences:   ICD-10: Z11.51, encounter for screening for HPV, and Z01.411, encounter for gynecological exam (general)(routine) with abnormal findings, OR, Z01.419, encounter for gynecological exam (general)(routine) without abnormal findings.  30.7 - TOB and Revenue Codes for Form CMS -1450 (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 applicable bill types for screening Pap smears are 12X, 13X, 14X, 22X, 23X, and 85X.  Use revenue code 0311 (laboratory, pathology, cytology).  Report the screening pap smear as a diagnostic clinical laboratory service using one of the HCPCS codes show n in 30.5.B .  In addition, CAHs electing method II report professional services under revenue codes 096X, 097X, or 098X.   Effective April 1, 2006, TOB 14X is for non- patient laboratory specimens.  HPV Screening:  Effective for claims with dates of service on and after July 9, 2015, HCPCS G0476, Cervical cancer screening, all -inclusive HPV co -test with cytology (Pap smear) to detect HPV DNA or RNA sequences, shall be paid only on TOBs 12X, 13X, 14X, 22X, 23X, and 85X.    30.8 - MSN Messages (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  If there are no high risk factors, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed use MSN 18.17:   Medicare pays for a screening Pap smear and/or screening pelvic examination only once every (2, 3) years unless high risk factors are present.  HPV Screening: Effective for claims with dates of service on and after July 9, 2015:   A. If denying line -items on claims containing HCPCS G0476, HPV screening, when reported more than once in a 5- year period [at least 4 years and 11 full months (59 months total) must elapse from the date of the last screening], use the following messages:   (Part A Only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered.  An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.  C all 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD 210.2.1 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.2.1 fueron utilizadas cuando se tom esta decisin.   B. If denying line -items on claims containing HCPCS G0476, HPV screening, when the beneficiary is not between the ages of 30 -65, use the following messages:   (Part A Only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered.  An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.  C all 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD 210.2.1 were used when we made this decision."   Spanish Version  Las siguientes polticas NCD 210.2.1 fueron utilizadas cuando se tom esta decisin.   C. If denying line -items on claims containing HCPCS G0476, HPV screening, when the claim does not contain the appropriate ICD -10 diagnosis codes listed below:    ICD-10: Z11.51 and Z01.411 or, Z01.419  Use the following messages:   (Part A Only)MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered.  An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.  Call 1- 800-MEDICARE (1-800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD 210.2.1 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.2.1 fueron utilizadas cuando se tom esta decisin.    30.9 - Remittance Advice Codes (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Pap Smear Screening:  If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ANSI X12N 835:    Claim adjustment reason code 119 -  Benefit maximum for this time period has been reached at the line level, and    Remark code M83 - Service is not covered unless the patient is classified as at high risk at the line item level.   HPV Screening: Effective for claims with dates of service on and after July 9, 2015:   A. If denying line -items on claims containing HCPCS G0476, HPV screening, when reported more than once in a 5- year period [at least 4 years and 11 months (59 months total) must elapse from the date of the last screening], use the following messages:   CARC 119: Benefit maximum for this time period or occurrence has been reached.   RARC N386: This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file).