Physicians and coders continue to be confused about the correct way to report breast and pelvic examinations with or without obtaining a Papanicolaou (Pap) test when the examination is performed as part of a preventive medicine or problem-oriented visit. This article teaches coding principles; be aware that current guidelines state that the first Pap test should be performed at 21 years of age, except if a patient has immune suppression or infection with HIV, in which case annual Pap tests are started with the onset of sexual activity (http://pediatrics.aappublications.org/content/126/3/583.full).

Medicare requires that Healthcare Common Procedure Coding System Level II code Q0091 (screening Pap; obtaining, preparing, and conveyance of cervical and vaginal smear to laboratory) be reported separately with the appropriate E/M service. Some Medicaid programs and commercial payers may also recognize code Q0091 as a separate service. If reporting Q0091, it is not appropriate to also report...

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