CMS Pub. 100-04, ch. 18, § 30.6

Effective October 1, 2015 the below are the current diagnoses that should be used when billing for

screening Pap smear services

The following chart lists the diagnosis codes that CWF must recognize for high-risk patients for

every year screening Pap smear services.

ICD-10-CM Codes for PAP High Risk every year

ICD-10

CM code Definitions

Z77.29 Contact with and (suspected) exposure to other hazardous substances

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z77.9 Other contact with and (suspected) exposures hazardous to health

Z91.89 Other specified personal risk factors, not elsewhere classified

Z92.850 Personal history of Chimeric Antigen Receptor T-cell therapy

Z92.858 Personal history of other cellular therapy

Z92.86 Personal history of gene therapy

Z92.89 Personal history of other medical treatment

The following chart lists the diagnosis codes that CWF must recognize for low-risk for every 2

years

ICD-10-CM Codes for PAP Low Risk every 2 years

ICD-10

CM code Definitions

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z12.4 Encounter for screening for malignant neoplasm of cervix

Z12.72 Encounter for screening for malignant neoplasm of vagina

Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs

Z12.89 Encounter for screening for malignant neoplasm of other sites

A. Screening Pap Smears: Applicable Diagnoses for Billing A/B MAC (B)

There are a number of appropriate diagnosis codes that can be used in billing for screening Pap

smear services that the provider can list on the claim to give a true picture of the patient’s

condition. Those diagnoses can be listed in Item 21 of Form CMS-1500 or the electronic

equivalent (see Chapter 26 for electronic equivalent formats). In addition, one of the following

diagnoses shall appear on the claim: the low-risk diagnosis of Z01.411, Z01.419, Z12.4, Z12.72,

Z12.79, and Z12.89 or the high-risk diagnosis of, Z77.29, Z72.51, Z72.52, Z72.53, Z77.9, Z91.89,

Z92.850, Z92.858, Z92.86, and Z92.89. (Effective Oct 1, 2015) One of the above diagnoses must

be listed in item 21of the Form CMS-1500 or the electronic equivalent to indicate either low risk or

high risk depending on the patient’s condition. Then either the low-risk or high-risk diagnosis

must also be pointed to in Item 24E of Form CMS-1500 or the electronic equivalent. Providers

must make sure that for screening Pap smears for a high-risk beneficiary that the high-risk

diagnosis code appears in Item 21 that must be pointed to in Item 24E or the electronic equivalent.

If Pap smear claims do not point to one of these specific diagnoses in Item 24E or the electronic

equivalent, the claim will reject in the CWF. Periodically, A/B MACs (B) should do provider

education on diagnosis coding of Pap smear claims.

B. Screening Pap Smears: Applicable Diagnoses for Billing A/B MACs (A)

Providers report one of the following diagnosis codes in Form CMS-1450 or the electronic

equivalent (NOTE: Information regarding the form locator numbers that correspond to the

diagnosis codes and a table to crosswalk its CMS-1450 form locator to the 837 transaction is found

in Chapter 25.):

Low-risk ICD-10-diagnosis codes for every 2 years:

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z12.4 Encounter for screening for malignant neoplasm of cervix

Z12.72 Encounter for screening for malignant neoplasm of vagina

Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs

Z12.89 Encounter for screening for malignant neoplasm of other sites

High-risk ICD-10 diagnosis codes for every year:

ICD-10

CM code Definitions

Z77.29 Contact with and (suspected) exposure to other hazardous substances

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z77.9 Other contact with and (suspected) exposures hazardous to health

Z91.89 Other specified personal risk factors, not elsewhere classified

Z92.850 Personal history of Chimeric Antigen Receptor T-cell therapy

Z92.858 Personal history of other cellular therapy

Z92.86 Personal history of gene therapy

Z92.89 Personal history of other medical treatment

Periodically provider education should be done on diagnosis coding of Pap smear claims.

C. HPV Screening: Applicable Diagnoses for Billing A/B MAC (A/B)

Effective for claims with dates of service on or after July 9, 2015, providers shall report the

following diagnosis codes when submitting claims for HCPCS G0476 - Cervical cancer screening,

all-inclusive HPV co-test with cytology (Pap smear) to detect HPV DNA or RNA sequences:

ICD-10: Z11.51, encounter for screening for 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.

30.7 - TOB and Revenue Codes for Form CMS-1450

(Rev. 3460, Issued: 02-05-16, Effective: 07-09-16, Implementation: 03-07-16 - for non-shared MAC edits; 07-05-16 - CWF analysis and design; 10-03-16 - CWF Coding, Testing and Implementation, MCS, and FISS Implementation; 01-03-17 - Requirement BR9434.04.8.2)

The applicable bill types for screening Pap smears are 12X, 13X, 14X, 22X, 23X, and 85X. Use

revenue code 0311 (laboratory, pathology, cytology). Report the screening pap smear as a

diagnostic clinical laboratory service using one of the HCPCS codes shown in §30.5.B.

In addition, CAHs electing method II report professional services under revenue codes 096X,

097X, or 098X.

Effective April 1, 2006, TOB 14X is for non-patient laboratory specimens.

HPV Screening: Effective for claims with dates of service on and after July 9, 2015, HCPCS

G0476, Cervical cancer screening, all-inclusive HPV co-test with cytology (Pap smear) to detect

HPV DNA or RNA sequences, shall be paid only on TOBs 12X, 13X, 14X, 22X, 23X, and 85X.