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HCFA scuttles site-of-service Pap smear plan

Carl Graziano

The Health Care Financing Administration has revised a payment policy that would have determined the relative value of a physician's interpretation of a Pap smear by whether the service was provided in a hospital or an independent laboratory.

HCFA officials now say the agency will pay the same for such interpretations regardless of the site of the service. As with other physician fee schedule services, geographic adjustments will determine final payment for Pap smear interpretations in specific areas.

The government had published a two-tiered system of payment in the November final rule on the 1999 physician fee schedule. In that rule, the 1999 relative value unit, or RVU, for a Pap smear interpretation when provided in a hospital was set at 0.76, while the RVU for a service provided in an independent laboratory was set at 1.01. The difference? The resource-based practice expense RVU, which was set at 0.31 for a hospital-based pathologist's interpretation and 0.56 for an independent laboratory physician's interpretation.

The higher practice expense values published in November for services provided by independent laboratories mistakenly included an allocation for costs associated with the screening Pap smear, payment for which is made separately under the clinical laboratory fee schedule.

A HCFA program memorandum to all Part B carriers announced the change, which took effect Jan. 1. The 1999 RVUs for the Medicare physician Pap smear, regardless of where the service is provided, are 0.42 for physician work, 0.31 for practice expense and 0.03 for malpractice, giving the service a total value of 0.76.

Medicare began on Jan. 1 paying separately for physician Pap smear interpretations for outpatients if the laboratory screening personnel suspect an abnormality and the physician reviews and interprets the Pap smear, even if the Pap smear is interpreted as showing no abnormality.

The physician fee schedule final rule that established separate payment for Medicare outpatient physician interpretations of Pap smears reiteriated a clinical laboratory improvement amendments requirement for such review.

CLIA 88 regulations require a pathologist's confirmation of abnormalities found during an initial Pap smear screening. Such abnormalities, the regulations state, include "reactive or reparative changes, atypical squamous or glandular cells of undertermined significance, or to be in the premalignant (dysplasia, cervical intraepithelial neoplasia or all squamous intrepithelial lesions including human papilloma virus associated changes) or malignant category."

An article on the use of CPT coding for Pap smear interpretations in the December 1998 issue of the "CPT Assistant" newsletter, published by the American Medical Association, also touched on the CLIA requirement.

In the article, the College, working with the AMA, responded to the question, "Is the code for physician interpretation of a Pap smear, 88141, to be used to report rescreening of negative Pap smears for quality control?" The published response said that, considering the interpretation code terminology and the CLIA requirements, negative Pap smears that do not require a physician's interpretation, including smears reviewed for quality control purposes, should not be coded with the physician interpretation code.

The interpretation code should be used to report physician interpretation of a smear identified as abnormal in initial screening. This includes smears interpreted to be showing suspicious or malignant cells, epithelial cell abnormality (atypical cells of undetermined significance, for example) or cellular changes simulating epithelial cell abnormality, such as repair, radiation effect, and cellular changes associated with viral infection, the article states.

Reprinted from February 1999 CAP TODAY

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