Date of Service: 10-1-15

Requisition: Annual Pap – cervical, routine screening. Thin layer preparation. Reflex HPV 16, 18 if ASCUS.

Cytotechnologist’s Pap Screening Review: Epithelial cell abnormalities. Specimen is adequate for evaluation, and endocervical transformation zone present.

Pathologist’s Interpretation: Epithelial cell abnormalities – (ASCUS) Atypical squamous cells of undetermined significance are present.

HPV genotyping for types 16 and 18 only: Negative for types 16 and 18.

What are the appropriate CPT and ICD-10 codes for this scenario?

SpecimenCPT and ICD10-CM Codes

Liquid-based Pap

88142   Z12.4

Liquid-based Pap - Interpretation

88141   Z12.4, R87.610

Reflex HPV Genotyping 16 and 18

87625   R87.610

CPT Code Descriptors:

CPT CodeDescriptors

88142

Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

88141

Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician

87625

Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed

ICD10-CM Code Descriptors and Breakdown: Z12.4  Encounter for screening for malignant neoplasm of cervix

Alpha Index: Screening – neoplasm (malignant) (of) – cervix Z12.4. The four character code is broken down as follows:

  • Z12 is the primary descriptor for Encounter for screening for malignant neoplasms
  • 4th digit of “4” defines the anatomic site as cervix

R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix [ASCUS]

Alpha Index: ASCUS (atypical squamous cells of undetermined significance on cytologic smear) – cervix R87.610. The six character code is broken down as follows:

  • R87.6 is the primary descriptor for abnormal cytological findings in specimens from female genital organs.
  • 5th digit of “1” defines the anatomic site of the abnormal cytologic finding as cervix.
  • 6th digit of “0” further classifies the abnormal cytologic cervical finding as ASCUS.

The referring physician ordered a routine screening cervical Pap evaluation, and a thin-layer slide was prepared. The cytotechnologist performed the initial screening review, which detected an abnormality.  Report this initial screening with CPT code 88142. Since this is a clinical laboratory test; therefore, the diagnosis code selection is based on the reason for testing provided by the referring physician; routine screening, reported as Z12.4.

Due to the detected abnormality, the pathologist’s interpretation is required, and should be reported as 88141. The primary ICD-10 diagnosis code for this service is also based on the referring physician’s reason for testing; routine screening (Z12.4). The pathologist’s finding of ASCUS is reported as the secondary diagnosis code.

HPV genotyping for types 16 and 18 was performed at the request of the referring physician, due to the Pap diagnosis of ASCUS. CPT code 87625 should be assigned for this service, and since the genotyping was negative, the diagnosis code is based on the ASCUS Pap diagnosis (R87.910).

References:

  • 2015 CPT Professional Edition Manual, American Medical Association, pages 532, 535.
  • 2016 ICD 10-CM Manual, American Medical Association, pages 274, 1112, 30, 835.
  • CMS Transmittal 1504; National Coverage Determination (NCD) 210.2.
Author - Female

About the author

Beth McDevitt, CPC is Compliance - National Pathology Coding Manager, Auditing, Pathology and Laboratory of McKesson Business Performance Services