Medicare Part B Local Coverage Determination

"CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply."

Contractor’s Determination Number: AC-01-014
Contractor Name: Medicare Services
Contractor Number: 00520, 00521, 00522, 00523, 00524, 00528
Contractor Type: Carrier
AMA CPT Copyright Statement: "CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply."
CMS National Coverage Policy:
  • Title XVIII of the Social Security Act, section 1862(a)(7). This section excludes payment for routine physical examinations or screening services (unless otherwise specified).
  • Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically necessary.
  • Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment of any claim which lacks the necessary information to process the claim.
Primary Geographic Jurisdiction: 00520 - Arkansas
00521 - New Mexico
00522 - Oklahoma
00523 - Missouri (Eastern)
00524 – Rhode Island
00528 - Louisiana
Oversight Region: Region I Boston (RI) Region VI Dallas (AR, LA, MO, NM, OK)
CMS Consortium: Northeast (RI) Southern (AR, LA, MO, NM, OK)
DMERC Region LCD Covers Not applicable
Original LCD Effective Date: 03/01/2007 (RI) 04/15/2002 (AR, LA, MO, NM, OK)
Indications and Limitations of Coverage and/or Medical Necessity: The Pap smear provides for early detection of cervical carcinoma, before the lesion has advanced to the state where overt symptoms are present.
Previous cancer of the cervix, uterus, or vagina that has been or is presently being treated (V10.40-V10.44);
Previous abnormal pap smear (795.0);
Any abnormal findings of the vagina, cervix, uterus, ovaries, or adnexa (621.4, 622.1, 622.2, 623.0, 623.1, 623.5);
Any significant complaint by the patient referable to the female reproductive system; or
Any signs or symptoms that might in the physician’s judgement reasonably be related to a gynecologic disorder (in some cases, previous cancer in another site can be justification for performing a diagnostic pap smear).
Type of Bill Code: Not applicable
Revenue Codes: Not applicable
CPT/HCPCS Codes: This policy does not take precedence over the Correct Coding Initiative (CCI). Consult current correct coding guidelines for applicable specific code combinations or reductions in payment due to specific codes billed.
The following short descriptors are in accordance with the AMA copyright agreement. Please refer to the current CPT book for full descriptions.
88141 Cytopath, c/v, interpret
88142 Cytopath, c/v, thin layer
88143 Cytopath c/v thin layer redo
88147 Cytopath, c/v, automated
88148 Cytopath, c/v, auto rescreen
88150 Cytopath, c/v, manual
88152 Cytopath, c/v, auto redo
88153 Cytopath, c/v, redo
88154 Cytopath, c/v, select
88155 Cytopath, c/v, index add-on
88164 Cytopath tbs, c/v, manual
88165 Cytopath tbs, c/v, redo
88166 Cytopath tbs, c/v, auto redo
88167 Cytopath tbs, c/v, select
88174 Cytopath, c/v auto, in fluid (Effective 01/01/2003)
88175 Cytopath c/v auto fluid redo (Effective 01/01/2003)
ICD-9 Codes that Support

Medical Necessity:

180.0-180.9 Malignant neoplasm of cervix, uteri
182.0-182.8 Malignant neoplasm of body of uterus
184.0-184.9 Malignant neoplasm of other and unspecified female genital organs
233.1 Carcinoma in situ of cervix uteri
233.3 Carcinoma in situ of other and unspecified female genital organs
614.0-614.9 Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and peritoneum
615.0-615.9 Inflammatory diseases of uterus, except cervix
616.0-616.9 Inflammatory disease of cervix, vagina, and vulva
617.0-617.9 Endometriosis
618.00-618.9 Genital prolapse
619.0-619.9 Fistula involving female genital tract
620.0-620.9 Noninflammatory disorders of ovary, fallopian tube, and broad ligament
621.0-621.9 Disorders of uterus, not elsewhere classified
622.0-622.9 Noninflammatory disorders of cervix
623.0-623.9 Noninflammatory disorders of vagina
624.0-624.9 Noninflammatory disorders of vulva and perineum
625.0-625.9 Pain and other symptoms associated with female genital organs
626.0-626.9 Disorders of menstruation and other abnormal bleeding from female genital tract
627.0-627.9 Menopausal and postmenopausal disorders
628.0-628.9 Infertility, female
629.0-629.9 Other disorders of female genital organs
795.00-795.09 Nonspecific abnormal Papanicolaou smear of cervix
795.1 Nonspecific abnormal papanicolaou smear of other site
V10.40-V10.44 Personal history of malignant neoplasm of female genital organs
V15.89 Other specified personal history presenting hazards to health, other
V72.32 Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear
Diagnosis that Support Medical Necessity: Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity: Not applicable
Diagnosis Codes that DO NOT Support Medical Necessity: Not applicable
Documentation Requirements:  
Utilization Guidelines:  
Sources of Information and Basis for Decision: Local Medical Review polices from:
Arkansas PAP Smears, Diagnostic; and
Louisiana PAP Smears, Diagnostic.
Advisory Committee Notes: The Arkansas consortium combined policy was presented in December 2001 (AR, LA, MO, NM, OK) and September 2006 (RI) and accepted.
"This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the Gynecology and Cytopathology."
Start Date of Comment Period: 09/01/2006 (RI) 11/17/2001 (AR, LA, MO, NM, OK)
End Date of Comment Period: 10/31/2006 (RI) 01/15/2002 (AR, LA, MO, NM, OK)
Start Date of Notice Period: 01/12/2007 03/15/2002 (AR, LA, MO, NM, OK)
Revision History:
12/21/2006 Policy revised to include Rhode Island (00524). This policy was presented to the RI CAC on 9/26/2006, released on 1/12/2007 in the January 2007 newsletter, and effective with DOS 3/1/2007.
Removed 88144-88145 from LCD as these were deleted codes for 2003. Added CCI statement to HCPCS/CPT section.
08/08/2005 Effective with DOS 08/08/2005, added 233.3 to allow for patients with prior hysterectomy who warrant a diagnostic pap for carcinoma in situ of the vagina or vulva. Revised the 9/30 Revision History entry to include the year 2004.
09/30/2004 Reformatted to LCD.
Revised I&L to by moving second paragraph from previous Description to the beginning of the I&L.
Added specific deletion and effective dates to CPT/HCPCS codes (from previous Coding GL #2).
Added new 2005 ICD-9 code V72.32 and expanded 618.0 to include 618.00 effective 10/01/2004.
Add Source reference to list specific LMRP titles.
01/17/2003 Effective with date of service 01/01/2003, added CPT codes 88174-88175 and deleted CPT codes 88144-88145. Expanded ICD-9-CM code 795.0 to allow 795.00-795.09, effective 10/01/2002. These additions are due to the 2003 coding updates. ICD-9-CM codes 233.1 and 795.1 were added to allow, retroactive to the effective date of the policy.
06/26/2002 Diagnosis code 795.0 was added to the ICD-9-CM section. (AC-2002-02).