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Screening Pap Tests & Pelvic ExamsCPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved.Applicable FARS/HHSAR apply. CPT is a registered trademark of the American Medical Association. Fee schedules, relativevalue units, conversion factors and or related components are not assigned by the AMA, are not part of CPT, and the AMAis not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. TheAMA assumes no liability for data contained or not contained herein.Copyright 2021, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of theAmerican Hospital Association (AHA) copyrighted materials contained within this publication may be copied without theexpress written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not beremoved, copied, or utilized within any software, product, service, solution or derivative work without the written consent ofthe AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizingthe content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be usedin any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions;and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is onlyauthorized with an express license from the American Hospital Association.To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshallat (312) 893-6814. You may also contact us at ub04@aha.org.The American Hospital Association (the “AHA”) has not reviewed, and is not responsible for, the completeness or accuracy ofany information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material,or the analysis of information provided in the material. The views and/or positions presented in the material don’t necessarilyrepresent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.Page 1 of 12MLN909032 April 2022
Screening Pap Tests & Pelvic ExamsMLN BookletTable of ContentsWhat’s Changed? . 3Coverage Information . 4Documentation . 6Coding & Diagnosis Information. 6Billing Requirements. 9Payment Information . 10Claim Denial Reasons .11Resources . 12Page 2 of 12MLN909032 April 2022
Screening Pap Tests & Pelvic ExamsWhat’s Changed?We added 3 ICD-10 diagnosis codes: Z92.850, Z92.858, and Z92.86 (page 8).You’ll find substantive content updates in dark red font.Page 3 of 12MLN909032 April 2022MLN Booklet
Screening Pap Tests & Pelvic ExamsImportant female preventive health care includes screeningPap tests and pelvic exams: A screening Pap test (called a Pap smear) is a lab testused to detect early cervical cancer. A health care providertakes a cervical cell sample and interprets the test results. A screening pelvic exam helps detect precancers, genitalcancers, infections, Sexually Transmitted Infections (STIs),reproductive system abnormalities, and other genital andvaginal problems.Note: Human Papillomavirus (HPV) screening is alsoa preventive service. The test detects the virusthat causes cervical cancer and or warts. Sections210.2 and 210.2.1 of Medicare National CoverageDeterminations Manual, Chapter 1, Part 4 hasmore information.Coverage InformationMLN BookletTogether we can advancehealth equity and help eliminatehealth disparities for all minorityand underserved groups. Findresources and more from theCMS Office of Minority Health: Health Equity TechnicalAssistance Program Disparities Impact StatementFemale Preventive ScreeningsWe cover Pap smears,pelvic exams, STI, and HPVscreenings. They’re similarservices, but separate benefits.Medicare Part B covers all female patient screening Pap tests and pelvic exams (including clinicalbreast exams) when ordered and performed by 1 of these medical professionals authorized understate law: Doctor of medicine or osteopathy Certified nurse-midwife Physician assistant Nurse practitioner Clinical nurse specialistPart B covers an HPV screening with a Pap test once every 5 years for all female patients ages 30–65.Page 4 of 12MLN909032 April 2022
Screening Pap Tests & Pelvic ExamsMLN BookletCoverage FrequencyTable 1 describes how often Part B covers screening Pap tests, pelvic exams, and HPV screening.Table 1. Medicare-Covered Screening Pap Tests, Pelvic Exams, & HPV ScreeningHow OftenEvery 24 months (atleast 23 months after themost recent screeningPap test or pelvic exam)Annually (at least 11months after the mostrecent screening Paptest or pelvic exam)HPV Screening: Onceevery 5 years (at least4 years and 11 months[59 months total] afterthe most recent HPVscreening)Covered forAdditional InformationAny asymptomatic female patientN/AA female patient who meets 1 ofthese criteria: Evidence (based on her medicalhistory or other findings) thatshe’s at high risk for developingcervical or vaginal cancer andher physician (or authorizedpractitioner) recommends shehave the test more frequentlythan every 2 years Woman of childbearing age*who had a screening pelvicexam or Pap test during any ofthe previous 3 years indicatingthe presence of cervicalor vaginal cancer or otherabnormalityAny asymptomatic female patientages 30–65 years when done witha Pap testHigh risk factors for cervical andvaginal cancer are: Early onset of sexual activity(under 16 years old) Multiple sexual partners (5 ormore in a lifetime) History of STI (including HumanImmunodeficiency Virus [HIV]infection) Fewer than 3 negative Paptests or no Pap tests within theprevious 7 years Diethylstilbestrol (DES)— exposed daughters ofwomen who took DES duringpregnancyRefer to Cervical Cancer Screeningwith HPV Test service in theMedicare Preventive Serviceseducational tool* Premenopausal woman of childbearing age and a physician or qualified practitioner determines childbearing age basedon medical history or other findings.Coinsurance or Copayment & DeductibleWe waive pap test, pelvic exam, and HPV screening coinsurance or copayment and Part B deductibleif the service meets all coverage conditions. However, a charge could apply if the patient sees a nonparticipating provider.Page 5 of 12MLN909032 April 2022
Screening Pap Tests & Pelvic ExamsMLN BookletDocumentationMedical records must document all coverage requirements.Coding & Diagnosis InformationProcedure Codes & DescriptorsYou can perform a screening Pap test and pelvic exam during the same patient encounter. You canalso perform an HPV screening during the same encounter on any asymptomatic female patient ages30–65 at the same time you provide a Pap test. When this happens, report both HCPCS procedurecodes as separate claim line items.Table 2. Screening Pap & HPV Tests HCPCS CodesHCPCS CodeG0123G0143G0144G0145G0147G0148G0476P3000Page 6 of 12Code DescriptorScreening cytopathology, cervical or vaginal (any reporting system),collected in preservative fluid, automated thin layer preparation, screening bycytotechnologist under physician supervisionScreening cytopathology, cervical or vaginal (any reporting system), collected inpreservative fluid, automated thin layer preparation, with manual screening andrescreening by cytotechnologist under physician supervisionScreening cytopathology, cervical or vaginal (any reporting system), collected inpreservative fluid, automated thin layer preparation, with screening by automatedsystem, under physician supervisionScreening cytopathology, cervical or vaginal (any reporting system), collected inpreservative fluid, automated thin layer preparation, with screening by automatedsystem and manual rescreening under physician supervisionScreening cytopathology smears, cervical or vaginal, performed by automatedsystem under physician supervisionScreening cytopathology smears, cervical or vaginal, performed by automatedsystem with manual rescreeningInfectious agent detection by nucleic acid (dna or rna); human papillomavirus(hpv), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) forcervical cancer screening, must be performed in addition to pap testScreening papanicolaou smear, cervical or vaginal, up to three smears, bytechnician under physician supervisionMLN909032 April 2022
Screening Pap Tests & Pelvic ExamsMLN BookletTable 3. Physician’s Interpretation: Screening Pap Tests HCPCS CodesHCPCS CodeG0124G0141P3001Code DescriptorScreening cytopathology, cervical or vaginal (any reporting system), collected inpreservative fluid, automated thin layer preparation, requiring interpretation byphysicianScreening cytopathology smears, cervical or vaginal, performed by automatedsystem, with manual rescreening, requiring interpretation by physicianScreening papanicolaou smear, cervical or vaginal, up to three smears, requiringinterpretation by physicianTable 4. Lab Specimen: Screening Pap Test HCPCS CodeHCPCS CodeQ0091Code DescriptorScreening papanicolaou smear; obtaining, preparing and conveyance of cervicalor vaginal smear to laboratoryNote: You may collect another specimen when a previously collected Pap smearscreening specimen sent to the clinical lab proves unsatisfactory and thelab can’t interpret the test results. To bill this re-test, annotate the claimusing HCPCS code Q0091 and modifier –76 (repeat procedure or serviceby same physician or other qualified health care professional).Table 5. Screening Pelvic Exam HCPCS CodeHCPCS CodeG0101Code DescriptorCervical or vaginal cancer screening; pelvic and clinical breast examinationCPT only copyright 2021 American Medical Association. All rights reserved.Page 7 of 12MLN909032 April 2022
Screening Pap Tests & Pelvic ExamsMLN BookletDiagnosis Codes & DescriptorsReport 1 of the Pap tests, pelvic exams, and HPV ICD-10-CM screening diagnosis codes listed inTable 6. Use the appropriate code to indicate the patient’s low- or high-risk status.Table 6. Screening Pap Tests & Pelvic Exams Diagnosis CodesRisk LevelICD-10-CMDiagnosis 92.850Z92.858Z92.86Page 8 of 12Code DescriptorEncounter for gynecological examination (general) (routine)with abnormal findings [Use additional code(s) to identifyabnormal findings]Encounter for gynecological examination (general) (routine)without abnormal findingsEncounter for screening for HPV (primary)Encounter for screening for malignant neoplasm of cervixEncounter for screening for malignant neoplasm of vaginaEncounter for screening for malignant neoplasm of othergenitourinary organsEncounter for screening for malignant neoplasm of other sitesHigh risk heterosexual behaviorHigh risk homosexual behaviorHigh risk bisexual behaviorContact with and (suspected) exposure to other hazardoussubstancesOther contact with and (suspected) exposures hazardous tohealthOther specified personal risk factors, not elsewhere classifiedPersonal history of other medical treatmentPersonal history of Chimeric Antigen Receptor T-cell therapyPersonal history of other cellular therapyPersonal history of gene therapyMLN909032 April 2022
Screening Pap Tests & Pelvic ExamsMLN BookletBilling RequirementsProfessional ClaimsReport the appropriate HCPCS code and corresponding ICD-10-CM diagnosis code when submitingprofessional claims. Include Place of Service (POS) codes on all professional claims to indicatewhere you provided the service.Institutional ClaimsReport the appropriate HCPCS code, Types of Bill (TOB), revenue code, and the corresponding ICD10-CM diagnosis code when submitting institutional claims.Type of Bills for Institutional ClaimsSubmit the claim with the appropriate TOB and associated revenue code listed in Table 7.Table 7. Screening Pap Tests & Pelvic Exams Facility Types, TOBs, & Revenue CodesFacility TypeTOBPap TestRevenue CodePelvic ExamRevenue CodeHospital Inpatient (Part B)Hospital OutpatientHospital Other Part B (Non-Patient LaboratorySpecimens, including Critical Access Hospital[CAH])*Skilled Nursing Facility (SNF) Inpatient Part BSNF OutpatientRural Health Clinic (RHC)Federally Qualified Health Center 1X or 73X77X85X03110311052X052X0311, 096X,097X, or 098X07700770052X052X0770* We don’t require your CAH patients be physically present when you collect the specimen, but they must be a CAHoutpatient. Patients must get CAH outpatient services on the same day you or a CAH employee collect the specimen,or a CAH provider-based entity must collect the specimen.** CAHs electing Method II report services under revenue codes 096X, 097X, or 098X.Page 9 of 12MLN909032 April 2022
Screening Pap Tests & Pelvic ExamsMLN BookletPayment InformationProfessional ClaimsWe pay screening Pap tests and HPV screening under the Clinical Laboratory Fee Schedule (CLFS),and screening pelvic exams under Medicare’s Physician Fee Schedule (PFS).Like other Medicare PFS services, the non-participating provider reduction and limiting chargeprovisions apply to all screening Pap test and pelvic exam services.Institutional ClaimsScreening Pap test or pelvic exam payment depends on the facility type providing the service. ExceptRHCs, FQHCs, and CAHs, we pay HCPCS codes G0123, G0143, G0144, G0145, G0147, G0148,G0476, and P3000 under the CLFS. Table 8 lists the other payment types depending on setting.Table 8. Screening Pap Tests & Pelvic Exams Facility Payment MethodsFacility TypeHospital Inpatient(Part B)*Hospital Outpatient*Hospital OtherPart B (NonpatientLab Specimens,including CAH)*SNF Inpatient Part B**SNF OutpatientRHCFQHCPage 10 of 12Pap & HPV TestsPayment SystemPelvic ExamsPayment SystemOutpatient Prospective PaymentSystem (OPPS) HCPCS code Q0091OPPS HCPCS code Q0091OPPS HCPCS code Q0091OPPSMedicare PFS HCPCS code Q0091Medicare PFS HCPCS code Q0091Part of the All-Inclusive Rate (AIR)paymentFQHC Prospective Payment System(PPS)Medicare PFSMedicare PFSPart of AIR paymentMLN909032 April 2022OPPSN/AFQHC PPS
Screening Pap Tests & Pelvic ExamsMLN BookletTable 8. Screening Pap Tests & Pelvic Exams Facility Payment Methods (cont.)Pap & HPV TestsPayment SystemPelvic ExamsPayment SystemMethod I: 101% of reasonabletechnical component(s) services costMethod I: 101% of reasonable costtechnical component(s) servicesMethod II: 101% of reasonabletechnical component(s) servicescost for, plus 115% of Medicare PFSprofessional component(s) servicesnon-facility rateMethod II: 101% of reasonabletechnical component(s) services,plus 115% of Medicare PFSprofessional component(s) servicesnon-facility rateFacility TypeCAH* We pay Maryland inpatient or outpatient hospital services according to the Maryland State Cost Containment Plan.** The SNF Consolidated Billing provision allows separate Medicare Part B screening Pap tests, pelvic exams, and HPVscreenings payment for patients in a skilled Part A stay; however, the SNF must submit these services on TOB 22X. TheSNF must pay the screening Pap tests and pelvic exams other facility types provide for patients in a skilled Part A stay.Claim Denial ReasonsWe may deny screening Pap tests, pelvic exams, and HPV screenings in several situations, including: Patient (not high risk) got a covered screening within the past 2 years Patient (high risk) got a covered screening within the past year Patient (high risk) got a covered HPV screening within the past 5 years (at least 4 years and 11 months[59 months total] after the most recent HPV screening)You may find specific payment decision information onthe Remittance Advice (RA). The RA gives additionalpayment adjustment codes information. For more claimsinformation, find your MAC’s website.Page 11 of 12MLN909032 April 2022Remittance Advice InformationHealth Care Payment and RemittanceAdvice has more information.
Screening Pap Tests & Pelvic ExamsMLN BookletResources CMS Beneficiary Notices Initiative (BNI) How to Use the MPFS Look-Up Tool National Cancer Institute: Cervical Cancer Information for Health Professionals Section 280.4 of Medicare Benefit Policy Manual, Chapter 15 (Screening Pap Smears) Sections 30 and 40 of Medicare Claims Processing Manual, Chapter 18, (Screening Pap Smearsand Screening Pelvic Exams) United States Preventive Services Task Force (USPSTF) Screening for CervicalCancer RecommendationsMedicare Learning Network Content Disclaimer, Product Disclaimer, and Department of Health & Human Services DisclosureThe Medicare Learning Network , MLN Connects , and MLN Matters are registered trademarks of the U.S. Departmentof Health & Human Services (HHS).Page 12 of 12MLN909032 April 2022
Screening Pap Tests & Pelvic Exams MLN Booklet Page 3 of 12 MLN909032 April 2022. What's Changed? We added 3 ICD-10 diagnosis codes: Z92.850, Z92.858, and Z92.86 (page 8).
