Billing for pap smears in a physician practice can be confusing for clinicians and coders alike.

• Pap smears can be screening services or diagnostic services
• There is a HCPCS code for obtaining a screening pap smear, Q0091
• Performing a pelvic exam is either part of a preventive medicine service or problem oriented visit
• A new CPT® code in 2024: add-on code for performing a pelvic exam, 99459 (page down to read about it)

Clinicians often ask what codes to use when billing for a pap smear provided during a preventive medicine service or other problem-oriented E/M visit.  The only CPT^® codes specifically for pap smears are for use by a pathologist, for the interpretation of the cytology specimen. CPT^® codes in the lab section, 88000 series, should not be reported by the office physician who collects the pap smear.

What do I bill for pap smears done in a physician practice?

What does a gynecologist or primary care practitioner report for doing a pap smear at a visit?  The answer depends on the type of service, whether it is a screening test or a diagnostic test.  A screening test is done in the absence of symptoms, following preventive guidelines (there are two HCPCS codes, see below.) A diagnostic test is done because of a sign or symptom, condition, or a prior abnormal test result. And, there are two HCPCS codes for screening services, listed below.

Pap smear during a problem oriented visit

If a patient presents with a condition or complaint, such as discharge, pelvic pain or dysfunctional uterine bleeding, and the practitioner does a pelvic exam and collects a pap smear, bill an E/M service only.  Select the level of E/M service based on the key components of history, exam, and medical decision making, or time accumulated during the day of the visit. There is no additional charge for obtaining a pap smear during a problem oriented visit.

Do not report Q0091 (obtaining screen pap smear) for a diagnostic pap smear performed due to illness, disease or a symptom.

For example, the patient presents with dysfunctional uterine bleeding and as part of the work up, the clinician performs a pap smear.  The pelvic exam that the provider does is part of the E/M service. There isn’t a code to separately bill the pelvic exam that is part of a problem-oriented visit. As stated above and in this instance, it would be incorrect to bill the HCPCS code Q0091 for obtaining a screening pap smear, because the purpose of the visit and the pap is not screening, but diagnostic.

Pap smear during a preventive medicine services for a commercial patient

If the patient presents for a preventive medicine service, the pelvic exam is part of the age and gender-appropriate physical exam, as described by CPT^® codes in the 99381—99397 series of codes. However, for a screening pap, the HCPCS code for obtaining the screening pap smear, Q0091 may be used. Although this is a HCPCS code developed by CMS for Medicare patients, many commercial payers also recognize the code.  CPT® codes 99381–99397 include an age and gender-appropriate history and physical exam for both new and established patients. Note that G0101, pelvic and clinical breast exam, would be considered double-billing on the day of a CPT preventive visit.

G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination (Ca screen; pelvic/breast exam )

Q0091 Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory  (Obtaining screen pap smear)

+99459 Pelvic examination (list separately in addition to code for primary procedure)

+99459 Pelvic examination (add-on code)

CPT® introduced this code in 2024 as an add-on code to new and established patient visit codes  99202–99205, 99212–99215, consultation codes 99242–99245 and preventive medicine codes. 99383–99387 (new patients), 99393–99397 (established patients). It is an active code in the physician fee schedule without wRVUs assigned to it. It is to cover the practice expense for performing a pelvic exam. When the AMA’s RVS Update Committee (RUC) values practice expense codes they include both staff time and supplies. This code is valued at 4 minutes of staff time and a supply kit of $20. That doesn’t mean you’ll get paid $20 outright, but that is the national cost built into valuing the code.

At the 2024 AMA CPT symposium, the Q&A included this question: Is a chaperone required in order to report add-on code 99459? Their answer is no. They state that 99459 was developed to capture additional practice resources needed when a pelvic exam is performed, pointing out that the code is a practice expense only code. They state that while the valuation includes a chaperone, it is not required to report the code. This makes sense, because in addition to staff expense, a pelvic exam has supply expense.

We know that there is additional staff time in setting up the room for a pelvic, and if a pap is done, for preparing and transmitting the specimen.  The 2025 total RVUs in both a facility and non-facility are .68, so the national reimbursement with a conversion factor of $32.35 is about $22 (be sure to check the current conversion factor and PartB RVU spreadsheet to calculate the final reimbursement.

• Use the code for both preventive and problem visits
• Neither CPT® nor CMS in its publications mentions diagnosis coding, but use the code for the primary E/M procedure

Pap smear during a Medicare wellness visit

Medicare doesn’t pay for routine services, but it does pay for a cervical/vaginal cancer screening with a breast exam.  (Medicare pays for wellness visits, not discussed here. There are articles and videos on CodingIntel that discuss the Welcome to Medicare visit and initial and subsequent wellness visits.)  A patient can have this service annually with a high risk diagnosis and every two years with a low risk diagnosis.  High and low risk diagnosis codes are listed in the reference sheet below. (Click image to enlarge).

A Medicare patient may have a pelvic and clinical breast exam performed alone as the only service performed that day, at the time of a problem oriented visit or on the day of a wellness visit.  There is a HCPCS code for this, G0101.

Do not bill HCPCS code G0101 in addition to a preventive service reported with CPT^® codes 99381—99397.  Those codes include an age and gender appropriate physical exam and if needed, the pelvic and breast exam is part of that service. Most commercial payers do not recognize G0101.

G0101 requires a breast exam and a total of 7 of these exam elements to report G0101:  

• Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge
• Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses
• External genitalia
• Urethral meatus
• Urethra
• Bladder
• Vagina
• Cervix
• Uterus
• Adnexa/parametria
• Anus and perineum

There is no code for performing the breast exam alone on a Medicare patient who does not need the other screening exam elements.

Summary of pap smear billing guidelines

• If a clinician is reporting CPT^® preventive medicine services, and also performing a screening pap smear report a code in 99381-99397 series and Q0091.
• If reporting an E/M code for a symptom or condition and the practitioner also obtains a pap smear, report only the E/M service. Do not report Q0091 because it is used only for obtaining a screening test. Also report add on code +99459
• Use G0101 and Q0091 for Medicare patients receiving a screening pelvic and breast exam and also a screening pap smear. There are frequency limits for this service.

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