Diagnostic Pap Tests (L31080)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
L31080 LCD Title Diagnostic Pap Tests Contractor's Determination Number GU-020 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 11/15/2010 Original Determination Ending Date Revision Effective Date For services performed on or after 02/21/2011 Revision Ending Date |
The Pap test (sometimes called a Pap smear but more correctly called cervicovaginal cytology) is a way to examine cells collected from the cervix and vagina. This test can show the presence of infection, inflammation, abnormal cells, or cancer.
Indications:
A diagnostic Pap test and related medically necessary services are covered under Medicare Part B when ordered by a physician under one of the following conditions:
Previous cancer of the cervix, uterus, or vagina that has been or is presently being treated;
Previous abnormal pap test;
Any abnormal physical findings of the vagina, cervix, uterus, ovaries, or adnexa;
Any significant complaint by the patient referable to the female reproductive system; or
Any signs or symptoms that might in the physician s judgment reasonably be related to a gynecologic disorder.
Previous cervical biopsies performed for abnormality, suspected precancerous or cancerous condition
Previous hysterectomy for cervical abnormality
Previous HPV positive screening test in the last year.
Limitations:
Cervical and vaginal cytology do not require interpretation by a physician (usually a pathologist) 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 under the physician fee schedule 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 88141.
Cyto-hormonal study (88l55) is not intended for use as a routine service. Cyto-hormonal study (88155) is not recommended although it has been cited as helpful in the evaluation of certain kinds of endocrine abnormalities (e.g., infertility, failure to ovulate, possible abnormal sexual development.) The specimen is performed on the lateral vaginal wall and NOT as a cervico-vaginal sample. Only claims submitted for conditions such as this should be coded as 88155.
Types of Technology
Conventional Pap smear (88150, 88153, 88164 or 88165). This is the traditional method where the care provider obtains a specimen from the cervix and/or vagina, smears it directly on a slide and then immediately fixes the specimen (spray or immersion) immediately in the office. The slide(s) is sent to the cytology laboratory, where it is processed and stained and subsequently screened by a cytotechnologist. If necessary, it is then interpreted by a pathologist (88141). The laboratory reporting format is either The Bethesda System (88164 or 88165) or any other descriptive system (88150 or 88153).
Liquid-based cervicovaginal cytology (thin layer preparation) (88142 or 88143). This is an alternative to the conventional Pap smear. The care provider obtains a specimen from the cervix and/or vagina, then immediately transfers it to a container of proprietary fixative. The container is sent to the cytology laboratory, where an instrument (example- ThinPrep „¢. Hologic Corp; BD SurePath „¢, BD Corp.) is used to produce a concentrated thin layer cell preparation. The preparation is then stained and subsequently screened by a cytotechnologist. If necessary, it is then interpreted by a pathologist (88141). The preferred reporting format is The Bethesda System, but any descriptive reporting system may be used (88141 or 88143). The diagnostic advantages are that some obscuring factors (blood, mucus, inflammatory cells) are removed and cells of interest are evenly dispersed in an easier to view circumscribed monolayer.
Computer-assisted screening or re-screening: (88147, 88148, 88152, 88154, 88166, 88167, 88174 or 88175). These procedures are performed in the cytology laboratory using either type of specimen above. Stained slides are read on a special microscope linked to a computer with image analysis software. Various systems are in use either for initial screening of slides (88147, 88148, 88174 or 88175) or for re-screening of cases negative for intraepithelial lesion or malignancy on initial review (88152, 88154, 88166, 88167).
Coding Information
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 014x | Hospital - Laboratory Services Provided to Non-patients |
| 018x | Hospital - Swing Beds |
| 021x | Skilled Nursing - Inpatient (Including Medicare Part A) |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 023x | Skilled Nursing - Outpatient |
| 071x | Clinic - Rural Health |
| 077x | Clinic - Federally Qualified Health Center (FQHC) |
| 085x | Critical Access Hospital |
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 0311 | Laboratory Pathology - Cytology |
| 0923 | Other Diagnostic Services - Pap Smear |
| 88141 | CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), REQUIRING INTERPRETATION BY PHYSICIAN |
| 88142 | CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION |
| 88143 | CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION |
| 88147 | CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY AUTOMATED SYSTEM UNDER PHYSICIAN SUPERVISION |
| 88148 | CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY AUTOMATED SYSTEM WITH MANUAL RESCREENING UNDER PHYSICIAN SUPERVISION |
| 88150 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION |
| 88152 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING UNDER PHYSICIAN SUPERVISION |
| 88153 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION |
| 88154 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING USING CELL SELECTION AND REVIEW UNDER PHYSICIAN SUPERVISION |
| 88155 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL, DEFINITIVE HORMONAL EVALUATION (EG, MATURATION INDEX, KARYOPYKNOTIC INDEX, ESTROGENIC INDEX) (LIST SEPARATELY IN ADDITION TO CODE[S] FOR OTHER TECHNICAL AND INTERPRETATION SERVICES) |
| 88164 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); MANUAL SCREENING UNDER PHYSICIAN SUPERVISION |
| 88165 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION |
| 88166 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING UNDER PHYSICIAN SUPERVISION |
| 88167 | CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING USING CELL SELECTION AND REVIEW UNDER PHYSICIAN SUPERVISION |
| 88174 | CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; SCREENING BY AUTOMATED SYSTEM, UNDER PHYSICIAN SUPERVISION |
| 88175 | CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; WITH SCREENING BY AUTOMATED SYSTEM AND MANUAL RESCREENING OR REVIEW, UNDER PHYSICIAN SUPERVISION |
ICD-9 Codes that Support Medical Necessity
Infection
| 016.70 - 016.76 | TUBERCULOSIS OF OTHER FEMALE GENITAL ORGANS UNSPECIFIED EXAMINATION - TUBERCULOSIS OF OTHER FEMALE GENITAL ORGANS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) |
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 054.10 - 054.12 | GENITAL HERPES UNSPECIFIED - HERPETIC ULCERATION OF VULVA |
| 078.10 - 078.19 | VIRAL WARTS UNSPECIFIED - OTHER SPECIFIED VIRAL WARTS |
| 079.4 | HUMAN PAPILLOMAVIRUS IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE |
| 090.0 - 099.9 | EARLY CONGENITAL SYPHILIS SYMPTOMATIC - VENEREAL DISEASE UNSPECIFIED |
| 131.00 | UROGENITAL TRICHOMONIASIS UNSPECIFIED |
| 131.01 | TRICHOMONAL VULVOVAGINITIS |
| V01.6 | CONTACT WITH OR EXPOSURE TO VENEREAL DISEASES |
| V02.7 | CARRIER OR SUSPECTED CARRIER OF GONORRHEA |
| V02.8 | CARRIER OR SUSPECTED CARRIER OF OTHER VENEREAL DISEASES |
Neoplasm
| 158.8 | MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM |
| 171.6 | MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS |
| 179 - 184.9 | MALIGNANT NEOPLASM OF UTERUS-PART UNS - MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED |
| 195.3 | MALIGNANT NEOPLASM OF PELVIS |
| 197.6 | SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM |
| 198.6 | SECONDARY MALIGNANT NEOPLASM OF OVARY |
| 198.82 | SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS |
| 218.0 - 221.9 | SUBMUCOUS LEIOMYOMA OF UTERUS - BENIGN NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED |
| 233.1 - 233.39 | CARCINOMA IN SITU OF CERVIX UTERI - CARCINOMA IN SITU, OTHER FEMALE GENITAL ORGAN |
| 236.0 - 236.3 | NEOPLASM OF UNCERTAIN BEHAVIOR OF UTERUS - NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED FEMALE GENITAL ORGANS |
| 239.5 | NEOPLASM OF UNSPECIFIED NATURE OF OTHER GENITOURINARY ORGANS |
Ovarian Dysfunction
| 256.0 - 256.9 | HYPERESTROGENISM - UNSPECIFIED OVARIAN DYSFUNCTION |
Inflammatory disease
| 614.0 - 616.9 | ACUTE SALPINGITIS AND OOPHORITIS - UNSPECIFIED INFLAMMATORY DISEASE OF CERVIX VAGINA AND VULVA |
Other disorders of female genital tract
| 617.0 - 617.9 | ENDOMETRIOSIS OF UTERUS - ENDOMETRIOSIS SITE UNSPECIFIED |
| 620.0 - 621.8 | FOLLICULAR CYST OF OVARY - OTHER SPECIFIED DISORDERS OF UTERUS NOT ELSEWHERE CLASSIFIED |
| 622.2 - 622.9 | LEUKOPLAKIA OF CERVIX (UTERI) - UNSPECIFIED NONINFLAMMATORY DISORDER OF CERVIX |
| 623.0 | DYSPLASIA OF VAGINA |
| 623.1 | LEUKOPLAKIA OF VAGINA |
| 623.5 | LEUKORRHEA NOT SPECIFIED AS INFECTIVE |
| 623.7 | POLYP OF VAGINA |
| 623.8 | OTHER SPECIFIED NONINFLAMMATORY DISORDERS OF VAGINA |
| 623.9 | UNSPECIFIED NONINFLAMMATORY DISORDER OF VAGINA |
| 624.6 | POLYP OF LABIA AND VULVA |
| 624.8 | OTHER SPECIFIED NONINFLAMMATORY DISORDERS OF VULVA AND PERINEUM |
| 625.70 | VULVODYNIA, UNSPECIFIED |
| 625.71 | VULVAR VESTIBULITIS |
| 626.0 - 626.9 | ABSENCE OF MENSTRUATION - UNSPECIFIED DISORDERS OF MENSTRUATION AND OTHER ABNORMAL BLEEDING FROM FEMALE GENITAL TRACT |
| 627.0 - 627.9 | PREMENOPAUSAL MENORRHAGIA - UNSPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDER |
| 654.10 - 654.14 | TUMORS OF BODY OF UTERUS UNSPECIFIED AS TO EPISODE OF CARE IN PREGNANCY - TUMORS OF BODY OF UTERUS POSTPARTUM CONDITION OR COMPLICATION |
| 654.80 - 654.84 | CONGENITAL OR ACQUIRED ABNORMALITY OF VULVA UNSPECIFIED AS TO EPISODE OF CARE IN PREGNANCY - CONGENITAL OR ACQUIRED ABNORMALITY OF VULVA POSTPARTUM CONDITION OR COMPLICATION |
| 760.76 | NOXIOUS INFLUENCES AFFECTING FETUS OR NEWBORN VIA PLACENTA OR BREAST MILK, DIETHYLSTILBESTROL [DES] |
| V10.40 - V10.44 | PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED FEMALE GENITAL ORGAN - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER FEMALE GENITAL ORGANS |
Dysplasia
| 622.10 - 622.12 | DYSPLASIA OF CERVIX, UNSPECIFIED - MODERATE DYSPLASIA OF CERVIX |
Symptoms
| 789.30 - 789.37 | ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP GENERALIZED |
| 789.39 | ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE |
Abnormal Pap test of cervix
| 795.00 | ABNORMAL GLANDULAR PAPANICOLAOU SMEAR OF CERVIX |
| 795.01 | PAPANICOLAOU SMEAR OF CERVIX WITH ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE (ASC-US) |
| 795.02 | PAPANICOLAOU SMEAR OF CERVIX WITH ATYPICAL SQUAMOUS CELLS CANNOT EXCLUDE HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (ASC-H) |
| 795.03 | PAPANICOLAOU SMEAR OF CERVIX WITH LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION (LGSIL) |
| 795.04 | PAPANICOLAOU SMEAR OF CERVIX WITH HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (HGSIL) |
| 795.05 | CERVICAL HIGH RISK HUMAN PAPILLOMAVIRUS (HPV) DNA TEST POSITIVE |
| 795.06 | PAPANICOLAOU SMEAR OF CERVIX WITH CYTOLOGIC EVIDENCE OF MALIGNANCY |
| 795.08 | UNSATISFACTORY CERVICAL CYTOLOGY SMEAR |
| 795.09 | OTHER ABNORMAL PAPANICOLAOU SMEAR OF CERVIX AND CERVICAL HPV |
| 795.10 | ABNORMAL GLANDULAR PAPANICOLAOU SMEAR OF VAGINA |
| 795.11 | PAPANICOLAOU SMEAR OF VAGINA WITH ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE (ASC-US) |
| 795.12 | PAPANICOLAOU SMEAR OF VAGINA WITH ATYPICAL SQUAMOUS CELLS CANNOT EXCLUDE HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (ASC-H) |
| 795.13 | PAPANICOLAOU SMEAR OF VAGINA WITH LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION (LGSIL) |
| 795.14 | PAPANICOLAOU SMEAR OF VAGINA WITH HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (HGSIL) |
| 795.15 | VAGINAL HIGH RISK HUMAN PAPILLOMAVIRUS (HPV) DNA TEST POSITIVE |
| 795.16 | PAPANICOLAOU SMEAR OF VAGINA WITH CYTOLOGIC EVIDENCE OF MALIGNANCY |
| 795.19 | OTHER ABNORMAL PAPANICOLAOU SMEAR OF VAGINA AND VAGINAL HPV |
For CPT code: 88155
| 259.0 | DELAY IN SEXUAL DEVELOPMENT AND PUBERTY NOT ELSEWHERE CLASSIFIED |
| 628.0 | INFERTILITY FEMALE ASSOCIATED WITH ANOVULATION |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Any NOT listed above
General Information
Specialty Advisors and
Sandra Aponte-Cipriani, MD, et al, Cervical Smears Prepared by an Automated Device Versus the Conventional Method A Comparative Analysis, The International Academy of Cytology Acta Cytologica, 95;
Raheela Ashfaq, MD, et al, Diagnostic Comparison of Thin Prep Slides and Papanicolaou Smears With and Without Infections, From the Departments of Pathology, Parkland Memorial Hospital, Dallas, Texas, Grady Memorial Hospital, Atlanta Georgia, and George Washington University, Washington, DC, USA;
Mary Corkill, MD, et al, Specimen Adequacy of Thin Prep Sample Preparations in a Direct-to-Vial Study, The International Academy of Cytology Acta Cytologica, 97;
James Linder, MD, et al, The Thin Prep Pap Test, The International Academy of Cytology Acta Cytologica, 97;
Ellen Sheets, MD, et al, Colposcopically Directed Biopsies Provide a Basis for Comparing the Accuracy of Thin Prep and Papanicolaou Smears, Journal of Gynecologic Techniques, Vol 1 No 1 1995.
Conference call with CMD s
Dawn H. Grohs, M.S., Impact of Automated Technology on the Cervical Cytologic Smear, The International Academy of Cytology Acta Cytologica, 98, pg s 165-170;
Stephen S. Raab, MD, et al, The Cost-Effectiveness of the Cytology Laboratory and New Cytology Technologies in Cervical Cancer Prevention, American Journal of Clinical Pathology, Vol 111: pg s. 259-266;
Adalsteinn D. Brown and Alan M. Garber, MD, PhD, Cost-effectiveness of 3 Methods to Enhance the Sensitivity of Papanicolaou Testing, JAMA, Vol. 281, No. 4, pg s. 347-353
D. Solomon, et al, The 2001 Bethesda System: Terminology for reporting results of cervical cytology, JAMA 2002; 287: 2114-2119
Thomas C. Wright, et al, 2001 Consensus Guidelines for the Management of Women with Cervical Cytological Abnormalities, JAMA 2002, Vol. 287, no 16, 2120-2129
Wisconsin 06/18/2010
Illinois 05/19/2010
Michigan 05/12/2010
Minnesota 05/06/2010
J5: Iowa, Kansas, Missouri, Nebraska 06/24/2010
Date of the Open Meeting: 04/22/2010
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 14 was changed
8/1/2010 - The description for Bill Type Code 18 was changed
8/1/2010 - The description for Bill Type Code 21 was changed
8/1/2010 - The description for Bill Type Code 22 was changed
8/1/2010 - The description for Bill Type Code 23 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0311 was changed
8/1/2010 - The description for Revenue code 0923 was changed
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
88141 descriptor was changed in Group 1
88142 descriptor was changed in Group 1
88147 descriptor was changed in Group 1
88148 descriptor was changed in Group 1
88150 descriptor was changed in Group 1
88152 descriptor was changed in Group 1
88153 descriptor was changed in Group 1
88154 descriptor was changed in Group 1
88155 descriptor was changed in Group 1
88164 descriptor was changed in Group 1
88165 descriptor was changed in Group 1
88166 descriptor was changed in Group 1
88167 descriptor was changed in Group 1
88174 descriptor was changed in Group 1
02/21/2011 €” In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
LCD Attachments
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Page Last Updated: Wednesday, 05-Oct-2011 11:29:27 CDT
