January is Cervical Cancer Awareness Month! The National Cervical Cancer Coalition (NCCC) states that More than 14,000 women in the United States are diagnosed with invasive cervical cancer yearly. Early prevention, such as screening and vaccinations, is the most effective in reducing and preventing the disease. Human papillomavirus (HPV) infection is known to be one of the leading causes of cervical cancer. However, despite the high rate of patients found with cervical cancer, when diagnosed, it is one of the most successfully treatable forms of cancer as long as it is detected early and managed effectively. A Pap test can detect cancer early, then treatment outcomes are better, and it allows for early detection of precancerous abnormalities that can be treated to prevent them from developing into cancers.
CMS will cover screening for cervical cancer with human papillomavirus (HPV) contesting under the following conditions:
Pap tests and pelvic exams to check for cervical and vaginal cancers. As part of the pelvic exam, Medicare also covers a clinical breast exam to check for breast cancer. Medicare covers these screening tests once every 24 months in most cases. However, if you’re at high risk for cervical or vaginal cancer or are of child-bearing age and have had an abnormal Pap test in the past 36 months, Medicare will cover these screening tests once every 12 months. They also cover HPV tests (as part of a Pap test) once every five years if you are aged 30-65 without HPV symptoms.
Diagnostic vs Screening Pap test:
Provider’s documentation determines whether the patient is being seen for a diagnostic or screening test and also determines the appropriate ICD-10CM code to select and submit. A diagnostic code should be used when there are signs or symptoms of the disease. If additional testing is done simultaneously with the Pap test, documentation should support the medical necessity of the conditions, and additional diagnosis codes may be applicable. To help you determine if a Pap test was performed for diagnostic purposes, here are a few things to consider when analyzing the documentation;
- Has the patient been treated for or is being treated for cancer of the cervix, uterus or vagina?
- Is the patient being seen for a follow-up on a previous abnormal Pap test? If so, when was the Pap test done?
- Did the examination show any vagina, cervix, uterus, ovaries or adnexa abnormalities?
- Is the patient experiencing any signs or symptoms that might be related to a gynecological exam?
Screening Pap tests are done in the absence of signs, symptoms or history when the following applies;
- The physician recommends the procedure
- The patient is of childbearing age
- The patient did not have any Pap tests in the past three years
Documentation & Diagnosis Coding
When auditing encounters, I always look for the following, a provider or other qualified healthcare professional documentation of history vs current or active treatment. If this is not documented clearly, it can lead to incorrect diagnosis code selection and a ripple effect of inconsistent documentation and denied claims. “No Evidence of Disease” (NED) and “history of cancer/neoplasm” terms should not be documented if the patient is still receiving active treatment. Per ICD 10 guidelines, Z85 “Personal History of Malignant Neoplasm” should be written if the patient is no longer receiving active treatment. “Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed diagnosis with the Z85 code used as a secondary code”.
When providers document and diagnose cervical cancer, documentation must be clear, up-to-date and accurate. This allows the diagnosis code to be coded to the highest level of specificity and not just “unspecified”. Some terminology to look out for are:
- Malignancy (primary vs secondary)
- Ca in situ
- Uncertain Behavior
- Unspecified Behavior
- Signs and symptoms vs confirmed diagnosis
- Overlapping sites
- History of vs Active Treatment
- On Hormonal Therapy
- Prior excision or eradication
Coders should query a provider for clarification if documentation is not clear. Providers and coders should also keep abreast of guidelines and new diagnosis changes effective every October 1 to ensure correct coding.
Some diagnosis codes that you may see when a patient is receiving diagnostic treatment might be the following;
- Endocervical cancer (C53.0)
- Exocervical cancer (C53.1)
- Overlapping lesion of cervix uteri (C53.8)
- Cervical cancer, unspecified (C53.9)
- Endometrial cancer (C54.1)
- Myometrial cancer (C54.2)
- Uterine fundal cancer (C54.3)
- Uterine cancer, unspecified (C55)
- Vaginal cancer (C52)
- History of cervical cancer (Z85.41)
- History of uterine cancer (Z85.42)
- History of vaginal cancer (Z85.44)
Some diagnosis codes used when screening Pap smears are performed without illness, disease, or symptoms are;
- Z01.411 Encounter for the gynecological exam with abnormal findings
- Z01.419 Encounter for the gynecological exam without abnormal findings
- Z12.4 Encounter for screening for malignant neoplasms of the cervix
- Z12.72 Encounter for screening for malignant neoplasm of vagina
- Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm (Used for follow-up vaginal Pap smear [status post hysterectomy for malignant condition])
Coders should carefully read the index for “Excludes”, “Includes”, and “Use Additional” when reporting the following diagnosis codes:
- Z11.51* Encounter for screening for human papillomavirus (HPV), And
- Z01.411 Encounter for gynecological exam (general)(routine) with abnormal findings, Or
- Z01.419 Encounter for gynecological exam (general)(routine) without abnormal findings
Despite being a preventable, treatable, curable disease, cervical cancer is responsible for significant suffering in women worldwide, especially in low- and middle-income countries. Our recent blog post on “Social Determinates of Health” addresses the importance of identifying and documenting social disparities that affect patients. For example, not having access to proper care, testing, vaccinations, or health insurance can prevent some patients from being treated and detecting cancer at an early stage. Providers should continue documenting this in their notes, making the proper referrals, and selecting the appropriate Z codes. The right to healthcare for adolescent girls and women and disparities in access to high-quality health services must continue to be a high priority and addressed. We should continue raising awareness in January and the other 11 months of the year.
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