The Pap test (sometimes called a Pap smear) is a way to examine cells collected from the cervix and vagina. This test can show the presence of infection, abnormal cells, or cancer.

Pap smears and/or pelvic examinations are considered "screening" when performed for women who have neither symptoms nor signs of disease.

A screening pelvic examination with or without specimen collection for smears and cultures, should include at least seven of the following eleven elements:

• 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 (e.g., general appearance, hair distribution, or lesions);
• urethral meatus (e.g., size, location, lesions, or prolapse);
• urethra (e.g., masses, tenderness, or scarring)
• bladder (e.g., fullness, masses or tenderness)
• vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);
• cervix (e.g., general appearance, lesions, or discharge);
• uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent, or support);
• adnexa/parametria (e.g., masses, tenderness, organomegaly, or nodularity); and,
  anus and perineum

Screening Pap Smears (G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091)

Payment may be made for a screening pap smear according to approved frequency schedules.

Screening Pap smears are covered when ordered and collected by a doctor of medicine or osteopathy or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under state law to perform the examination).

NOTE:

See Medicare Advantage Medical Policy Bulletin N-111 for guidelines on diagnostic Pap smears.

Screening Pelvic Examination (G0101, S0610, S0612) (including a clinical breast exam, S0613)

Members are entitled to one routine exam each calendar year.

A screening Pap smear or screening pelvic examination performed for women who do not meet the criteria outlined in the "Indications and Limitations of Coverage" section of this policy will be denied.

A covered evaluation and management visit and code Q0091 may be reported by the same physician for the same date of service if the evaluation and management visit is for a separately identifiable service. In this case, the 25 modifier must be reported with the evaluation and management service and the medical records must clearly document the evaluation and management service reported.

When code Q0091 is reported on the same day by the same physician as an evaluation and management service, combine the charges and pay only the evaluation and managenet service.  Payment for the evaluation and management service performed on the same date of service includes the allowance for Q0091.  A provider cannot bill the member separately for Q0091 in this case.

A covered evaluation and management visit and codes G0101, S0610, or S0612 may be reported by the same physician for the same date of service if the evaluation and management visit is for a separately identifiable service. In this case, the 25 modifier must be reported with the evaluation and management service and the medical records must clearly document the evaluation and management service reported.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Cervical and vaginal smears do not require interpretation by a physician unless the results are, or appear to be, abnormal. In such cases, a physician personally conducts a separate microscopic evaluation to determine the nature of an abnormality. Separate payment is allowed for patients in any setting if the laboratory's screening personnel suspect an abnormality and the physician reviews and interprets the Pap smear. This physician service should be reported using code G0124, G0141, or P3001, as appropriate.

Diagnosis code V76.49 (Special screening for malignant neoplasms, other sites) should be used when reporting a screening pelvic examination for an asymptomatic woman who does not have a uterus or cervix.

A screening Pap smear and a screening pelvic examination can be performed during the same encounter. When this happens, both procedure codes should be shown as separate line items on the claim. These services can also be performed separately during separate office visits.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Internet On-Line Manual, Pub. 100-3, Chapter 1, Section 210.2.

CMS Internet On-Line Manual, Pub. 100-4, Chapter 12, Section 60, Chapter 18, Sections 30, 40.

Program Memorandum B-97-15, CR #168

Program Memorandum B-98-16, CR #452

Transmittal 1675, CR 1254

Transmittal 1694, CR 1497

Transmittal AB-03-054, CR 2637

Transmittal 440, CR 3659

Transmittal 1541, CR 6085

One or more of the following diagnosis codes apply to screening pelvic exams and screening Pap smears.