Pap Smears
The following diagnoses/conditions are those justifying payment for pap smears. (This is not intended to be an all-inclusive list.)

Abnormal vaginal discharge: 131.00
Cervical ulcerations: 622.0
Cervicitis: 016.7, 616.0
Condyloma: 078.10-078.11, 091.3
Endometriosis: 617
Fibroma of cervix: 219.0
Follow up to previous or suspicious pap smear: 622.10-622.12, 795.00, 795.01, 795.02, 795.03-795.09, V10.40-V10.44
Menopausal syndrome: 627
Neoplastic disease: 218-221, 236.0-236.3, 616.8-616.9, 621.8, 654.10-654.14, 789.3
Pelvic malignancy: 158.8, 179-184, 195.3, 197.6, 198.6, 198.82, 233.1-233.3
Polyps or cysts, cervical or uterine: 616, 620.0-620.2, 620.8, 621.0, 621.8, 622.7-622.8, 654.60-654.64, 752.11, 752.41
Post-menopausal bleeding: 627.1
Pregnancy: 630-638, 640-676, V22, V23-V23.5, V23.8-V23.9
Vaginal bleeding of unknown origin (abnormal): 626.2, 626.6-626.9
Vaginal or vulvar lesions, any type: 221.2, 616.2, 623.0, 623.7-623.8, 624.6, 624.8, 654.8
Vaginitis, any type: 054.11, 098.0, 112.1, 131.00-131.01, 616.1, 627.3
Vulvitis and vulvovaginitis: 054.11, 098.2, 131.01, 616.1, 616.5
Women exposed to DES (Diethylstilbestrol) prior to birth

Payment may be made for pap smears performed to "rule out" a suspected condition that may be the cause of the patient's symptoms.

Cyto-hormonal study (88155) is used primarily to determine the need for, or possible response to, estrogen therapy and to evaluate the hormonal status in patients who have certain types of endocrine problems (e.g., failure to ovulate, possible abnormal sexual development, infertility, etc.) Payment may be made for the cyto-hormonal study (88155) in addition to the pap smear (88142-88154, 88164-88167, 88174, 88175).

Claims for pap smears with diagnoses/conditions other than those listed above should be denied on the basis of medical necessity. Individual consideration can be given if this decision is questioned.

Pap smears using the ThinPrep method of slide preparation are eligible for payment under codes 88142, 88143, 88174, 88175, G0123, G0124, G0143, G0144, G0145.

Pap smears supplemented with the PapNet or AutoPap computerized rescreening are eligible for payment under codes 88147, 88148, 88152, 88154, 88166, 88167, as appropriate.

When reported, payment may be made for the physician interpretation (G0124, G0141, P3001, 88141) in addition to the pap smear codes (88142-88154, 88164-88167, 88174, 88175, G0123, G0143, G0144, G0145, G0147, G0148, P3000).

When a provider obtains a specimen for a pap smear, then refers that specimen to a laboratory for examination, the cost of obtaining the specimen is included in the allowance for the gynecological examination or evaluation and management service. Payment should be made to the laboratory for the actual pap smear examination.

However, if there is a billing arrangement whereby the provider reimburses the laboratory for the pap smear examination, payment can be made to the provider for the pap smear. No payment should be made to the laboratory in this case.

See Medical Policy Bulletin V-35 for guidelines on routine/screening pap smears.

Speculoscopy

Date Last Reviewed:  01/2005

Speculoscopy (0031T, 0032T) is considered experimental/investigational. There is insufficient scientific evidence to support the use of speculoscopy in the triage of low grade atypical pap smears or for routine screening for cervical cancer. The clinical role of speculoscopy as a screening device remains undefined. A participating, preferred, or network provider cannot bill the member for the denied service.

HPV Testing
HPV testing of pap smears that have an interpretation of atypical cells of undetermined significance (ASCUS) (795.00-795.09) is considered medically necessary.  HPV testing of pap smears is not indicated for those with a definitive interpretation of cervical cancer. 

HPV testing of pap smears with normal results for asymptomatic women is considered screening and is covered for patients whose individual or group benefits provide coverage for this test as a routine/screening service.  Payment for screening HPV testing is limited to one test per calendar year for women age 30 or older. 

HPV testing is not intended to substitute for regular routine pap smear screening for cervical cancer. Nor is it intended to screen for women under 30 who have normal pap tests.  Although the rate of HPV infection in this group is high, most infections are short-lived and not associated with cervical cancer.

Description

Pap Smears
The pap smear is used as the primary screening test to detect cervical cancer in asymptomatic women.  It can also detect premalignant and malignant changes of the cervix or vagina and some changes due to noncancerous conditions such as inflammation from infections.

Speculoscopy
Most cases of invasive cervical cancer occur in the unscreened population. However, approximately one third can be attributed to screening failure (i.e., false-negative pap smear results). Speculoscopy (PapSure) is a technology employed to augment conventional cervical cytological screening to reduce the 30% false-negative rate. Speculoscopy uses a chemoluminescent light to illuminate the cervix to aid naked-eye or minimally magnified visualization of acetowhite changes on the cervix. In addition to its use as an adjunct to the pap smear for cervical cancer screening, speculoscopy has been used as a triage method to identify which patients with low grade atypical pap smears need further evaluation by colposcopy and biopsy.

HPV Testing
Human papillomavirus (HPV) has been associated with the development of cervical intraepithelial neoplasia (CIN) that can then progress to invasive cervical cancer.  Studies show that abnormal pap smears which are also HPV positive are more likely to be associated with abnormal colposcopic exams than abnormal pap smears that are HPV negative.  Women with normal pap smear results and no HPV infection are at a very low risk for developing cervical cancer. 

HPV testing (87620 or 87621) can be performed on the remaining liquid media used as part of the preparation of monolayer slides (e.g., ThinPrep pap smears).  This eliminates the need for the patient to return to the provider’s office for another visit to obtain another sample for HPV testing.  In addition, further testing (e.g., colposcopy) and treatment can be initiated sooner.

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.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Speculoscopy is considered an eligible service when determined medically necessary based on the patient’s condition.

PRN References

02/1998, New pap smear reporting adopted
08/2003, Coverage guidelines for HPV testing