Billing for pap smear

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

• Pap smears can be screening services or diagnostic services
• Performing a pelvic exam is part of a preventive medicine service or problem oriented visit
• There is a HCPCS code for obtaining a screening pap smear, Q0091

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. 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, if counseling dominates the visit. There is no additional charge for obtaining a pap smear during a problem oriented visit.

Do not report Q0091 for obtaining 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. 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 Medicare for Medicare patients, many commercial payers recognize the code.  Do not bill G0101, pelvic and clinical breast exam, on the day of a CPT preventive visit. CPT codes 99381–99397 include an age and gender appropriate history and physical exam. Billing G0101 would be double billing for that portion of the exam.

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)

Pap smear during a Medicare wellness visit

Medicare doesn’t pay for routine services, but 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, and the breast exam must be done 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 remainder of the screening exam elements.

Summary of pap smear billing guidelines

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

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