Reimbursement Advisor

Medicare coding guidelines for cancer screening

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Q Which CPT codes are recommended for low-risk and high-risk Medicare pelvic/breast exams for women aged 65 and older? Are the rules the same for non-Medicare third-party payers?

A For any screening pelvic/breast exam, Medicare requires that the alphanumeric Healthcare Common Procedure Coding System code (rather than a CPT preventive medicine code) you submit be linked to a specific ICD-9 code.

For the screening, you would report G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination), regardless of whether the patient is at low or high risk for cervical or vaginal cancer. Medicare only differentiates between the risk categories via the ICD-9 diagnostic code you use.

If the patient is at low risk, use ICD-9 code V76.2 (special screening for malignant neoplasms, cervix) or V76.49 (special screening for malignant neoplasms, other sites). Effective October 1, 2003, the code V76.47 (special screening for malignant neoplasms, vagina) may also be used. Note that V76.49 (and V76.47) is used only when the patient has had her uterus removed for reasons other than malignancy. If the patient is at high risk, the diagnosis changes to V15.89 (other specified personal history presenting hazards to health), along with a second code indicating which of Medicare’s 5 high-risk criteria applies. For a woman past childbearing age (which is all patients 65 or older), these criteria are:

  • early onset of sexual activity (under 16 years of age) or multiple sexual partners (5 or more in a lifetime)—use V69.2, high-risk sexual behavior;
  • history of a sexually transmitted disease (including HIV infection)—use V13.8, personal history of other diseases; V08, asymptomatic HIV; or 042, HIV infection;
  • fewer than 3 negative Pap smears within the previous 7 years—use the diagnosis known at the time of the last Pap smear (if normal, use the code V13.2 for personal history of genitourinary disorder to indicate a previous abnormal Pap result); and
  • diethylstilbestrol-exposed daughters of women who took the drug during pregnancy—use 760.76 (DES exposure).

Non-Medicare insurers have different rules: Unlike Medicare, they tend to pay for a comprehensive well-woman exam each year, billed using 1 of the CPT preventive medicine codes (99381 to 99397). The diagnostic coding is also different—specifically V72.3, gynecologic exam with Pap smear.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

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