Medicare Pap Test Guidelines
Medicare has adopted some very specific rules and conditions as to when a Pap test will be considered a medically necessary laboratory test and thus a "covered service" for Medicare beneficiaries. The referring provider (and not the laboratory) must designate all Pap tests as:
- Screening - low risk
- Screening - high risk
- Diagnostic (see guidelines below).
Low Risk Screening Pap Smear
- Generally defined as no suspicion of current atypia and no history of atypical findings.
- Medicare will cover a low risk screening Pap once every 2 years.
- An appropriate diagnosis code (ICD-9) must be submitted to indicate the medical necessity of the Pap smear. The diagnosis code sumitted must be in the patient's medical record.
V72.31 (Routine gynecological examination)
V76.2 (Special Screening for malignant neoplasm, cervix)
V76.47 (Special screening for malignant neoplasms, vagina)
V76.49 (Special Screening for malignant neoplasms, other sites) This code is to be used for women that do not have a cervix or uterus - ABN required if the frequency limitation is exceeded.
High Risk Screening Pap Smear
Based upon the referring physician's recommendation and the patient's medical history, that a Pap smear should be performed on a more frequent basis. These patients are at a higher risk for developing cervical or vaginal cancer based on the following risk factors:
- Early onset of sexual activity (Under 16 years)
- Multiple sexual partners (5 or more in a lifetime)
- History of STD (including HIV)
- Fewer than 3 negative Pap smears in 7 years
- DES exposed daughters
- Is of child bearing age and has had a Pap smear indicating cervical or vaginal abnormalities (during the preceding 3 years).
Medicare will cover a high risk screening Pap smear on an annual basis.
A High Risk screening Pap smear is indicated to Medicare by using the diagnosis V15.89 (other specified personal history presenting hazards to health). This code must correspond with the patient's medical record.
ABN required if the frequency limitation is exceeded.
Diagnostic Pap Smear
Is ordered by the referring physician when one or more of the following circumstances apply:
- Patient previously diagnosed with cancer of the cervix, vagina or uterus
- Patient has a previously abnormal Pap smear
- Patient presents with current abnormal findings of the cervix, vagina, uterus or ovaries or adnexa
- Patient presents with any significant complaint referable to the female reproductive system
- Patient shows any sign or symptom that might, in the referring physician's judgement, reasonably be related to a gynecological disorder.
Medicare covers Pap smears ordered as diagnostic with no time restrictions. Use the diagnosis code(s) that best describe the patient's acute problem.
