Coding Error #1: Not Insisting on Complete Requisition Forms for Pap Tests

Lab administrators and pathologists often fail to realize how frequently this error results in lost revenue to the laboratory. Incomplete information on the requisition can also impact the clinical service the laboratory provides to the referring physician. It may be timely to do audit current workflow to determine the error rate on Pap smear requisitions. If your lab team doesn’t know the precise number, it is likely to be higher than anyone imagines.

CLIA regulations clearly state that, for Pap smears, laboratories need to indicate “whether the patient had a previous abnormal report, treatment, or biopsy.” Unfortunately, Pap smears are often completed without proper information from the patient’s referring physician and without first documenting the patient’s prior Pap smear results. These costly mistakes can lead to reimbursement disputes and lack of reimbursement from Medicare.

Medicare will reimburse for 3 types of Pap tests:

1) Type 1 is a Pap test that is medically necessary for diagnosis. These tests must be based on qualifying diagnosis (LCD).

2) Type 2 is a high-risk screening Pap test. Medicare will reimburse for high-risk Pap test every year assuming definition criteria are properly met.

3) Type 3 is a low-risk screening Pap test. Medicare will reimburse for low-risk Pap tests every 2 years. If a Pap test is not reimbursable by Medicare, laboratories must have a signed ABN (Advance Beneficiary Notice) and use the proper modifier in order to bill the patient.

An anatomic pathology laboratory’s requisition form for Pap tests should be designed to capture all of the following information:

  • Patient, insurance, and testing information
  • Clinical information and patient history
  • ICD9 code or a narrative description

• Whether the pap test is for diagnostic or screening purposes
• If a screening, whether the Pap test is a high-risk or low-risk screening
• ABN (form R-131-L)

There are several effective secrets to ensure that your laboratory avoids the trap of having incomplete requisition forms for Pap smears. First, monitor requisitions on the front end, in the laboratory. Second, laboratories should keep up with code changes and continually update requisition forms. Third, referring physicians and office staff should be educated as to the importance of the requisition forms so they do their part to fill them out as completely as possible. Finally, a laboratory should never default to an ICD9 code simply because information was not provided by a referring physician. This goes along with our third point – educate the physician, your office staff, and, if necessary, the referring physician’s office staff to let all parties know that incomplete information about patients will not be tolerated!