Collect Hpv Pay With The Right Screening Versus Reflex Diagnoses

By Author: Nancy Rose
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Bring into line ‘medical necessity' with ICD-9 instruction.

Following an abnormal Pap, ordering a human papillomavirus (HPV) screen with a Pap test is not the same as ordering a reflex HPV screen. Even though ICD-9 instruction and coverage rules might look like at loggerheads, our experts can show you the way out:

Question: Should the doctor order a screening and/or reflex HPV Pap test (like 87621, Infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe method) with V73.81 (Special screening exam for human papillomavirus [HPV])?

What do you stand to gain from here: "Many ‘V' codes are paid as part of a screening benefit for patients who have those specific advantages," says Tina Burkhalter, billing manager with SouthEastern Pathology in Rome, Ga.

On the other hand, she says, "Tests ordered with diagnostic codes tend to go to the deductible," "We hear from patients complaining that ...
... they must pay for the HPV test as their insurer tells them we reported the ‘wrong' code."

Medical necessity points to 795.0x

Even though no national coverage policy exists for screening HPV testing to weigh up cervical cancer risk, many payers follow the consensus guidelines recommended by the American Society for Colposcopy and Cervical Pathology (ASCCP).

A core ASCCP recommendation is to screen for high-risk HPV DNA in patients over the age of twenty years with a Pap cytologic result of 795.01 (Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]). The guidelines also address the role of HPV with other Pap outcomes in special populations like recommending reflex HPV testing for postmenopausal women with cytologic findings of 795.03 (Papanicolaou smear of cervix with low grade squamous intraepithelial lesion [LGSIL]).

Important: If your payers have adopted any or all of these guidelines, you will need to report the Pap findings like 795.01 to show medical necessity when the lab ‘reflexes' the specimen to a high-risk HPV screen like 87621, after abnormal Pap.

For example, National Government Services has a LCD that points you to 795.00, 795.01, or 795.02, when right, to show medical necessity for 87621.

The recommendation for labs has been to use the abnormal Pap findings (795.xx) as the ordering diagnosis for a reflex HPV screening test," according to Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

ICD-9 points you to V73.81

The screening gynecological exam code (V72.31, Routine gynecological examination) used to serve for HPV test orders, however no more. ICD-9 added a text note: "Use more code to identify: human papillomavirus (HPV) screening (V73.81).

Those instructions point to the fact that you should go for V73.81 to order a screening HPV test in addition to a Pap test if the ordering physician wants the HPV test run irrespective of the Pap test result.