ABN Information

ABN Form Information

An Advance Beneficiary Notice (ABN) form is to be used when a Medicare patient is scheduled to receive a screening Pap test. Medicare pays for a diagnostic Pap test – see information below on what qualifies as a diagnostic pap test. The ABN form was revised by CMS in 2011.

Medicare covers screening Pap test as follows:

  • once every two years for asymptomatic women (those with no signs of symptoms of a problem), use diagnosis code Z12.4, Z12.72, Z12.79, or Z12.89 for low risk patients.
  • annually for women at high risk (see information below on what constitutes high risk), use diagnosis code Z77.22, Z77.9, Z91.89, Z92.89, Z72.51, Z72.52, or Z72.53 to indicate high risk.
  • annually for women of child bearing age who have had examination results indicating the presence of cervical or vaginal cancer or other abnormality within the preceding three years.  The term “woman of child bearing age” means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of child bearing age, based on her medical history or other findings.  Use diagnosis code Z91.89 or Z92.89 to indicate high risk.

Some Medicare managed care plans do not have the same coverage rules for a Pap test as Medicare and may or may not pay for a screening Pap test. Therefore, you need to have each Medicare patient (and patients with some Medicare managed care plans) complete an ABN form so that the patient will be aware of this limitation and that they will be billed for the test if Medicare does not pay our laboratory.

How to complete the ABN Form:

The form is the standard Medicare designed form and is simple to complete.

  • You should give the form to the Medicare patient prior to collecting the Pap test specimen.
  • You should enter the Patient’s name at the top of the form.  The identification number may be entered but is not required.  Check the box for the Screening Pap Test.
  • The patient should read the form, choose option 1, 2 or 3, and sign and date the form at the bottom.
  • You should then review the form, noting which option the patient has selected and give the second (yellow) copy to the patient.
  • If the patient selects Option 1 or Option 2, proceed with collection of the specimen and attach the first copy of the completed ABN to the requisition and send both documents to the lab along with the specimen.
  • If the patient selects Option 3, the patient does not wish to have the test completed and the specimen should not be collected or sent to the laboratory for processing.

To remain compliant with Medicare regulations, our laboratory must require that the ABN forms be completed for each Medicare patient having a pap test.  We ask your cooperation in completing this task so that we may continue to provide services for your patients.

ABN Forms are provided for your office and may be ordered from our laboratory.

Use the appropriate ICD-10 code for any of the following indications of high-risk status:

Cervical Cancer High Risk Factors

  • Early onset of sexual activity (under 16 years of age)
  • Multiple sexual partners (five or more in a lifetime)
  • History of a sexually transmitted disease (including HIV infection)
  • Fewer than three negative results on any Pap test within the previous 7 years

Vaginal Cancer High Risk Factor

  • DES (diethylstilbestrol) exposed women (daughters of women who took DES during pregnancy)

Diagnostic Pap Tests – Diagnosis Requirements

(Information extracted from Medicare Bulletin – May/June 2001)

Criteria for Diagnostic Pap Smear

When billing for a diagnostic Pap smear, it is necessary to accurately code the medical indication for the test.  A diagnostic Pap smear and related medically necessary services are covered under Medicare Part B when ordered by a physician under one of the following conditions:

1.    Previous cancer of the cervix, uterus, or vagina that has been or is presently being treated

2.    Previous abnormal pap smear

3.    Any abnormal findings of the vagina, cervix, uterus, ovaries, or adnexa

4.    Any significant complaint by the patient referable to the female reproductive system, or

5.    Any signs or symptoms that might, in the physician’s judgement, reasonably be related to a gynecologic disorder.

ICD-10 Codes That Support Medical Necessity: (updated 10/28/2015)

 

Code Description
Z85.40 Personal history of malignant neoplasm of female genital organ, unspecified
Z85.41 Personal history of malignant neoplasm of cervix uteri
Z85.42 Personal history of malignant neoplasm of other parts of uterus
Z85.43 Personal history of malignant neoplasm of ovary
Z85.44 Personal history of malignant neoplasm of other female genital organs
Z79.810 Z79.899 Long term (current) use of medications (see book for descriptions)
C55 Malignant neoplasm of uterus, part unspecified
C53.0 Malignant neoplasm of cervix uteri, endocervix
C53.1 Malignant neoplasm of cervix uteri, exocervix
C53.8 Malignant neoplasm of overlapping sites cervix uteri
C53.9 Malignant neoplasm of cervix uteri, unspecified
C54.0 Malignant neoplasm of isthmus uteri
C54.1, .2, .3, or .8 Malignant neoplasm of body of uterus (see book for specific sites)
C54.9 Malignant neoplasm of corpus uteri, unspecified
C56.9 Malignant neoplasm of unspecified ovary
C57.00 Malignant neoplasm of unspecified fallopian tube
C57.10 Malignant neoplasm of unspecified broad ligament
C57.20 Malignant neoplasm of unspecified round ligament
C57.3 Malignant neoplasm of parametrium
C57.4 Malignant neoplasm of uterine adnexa, unspecified
C52 Malignant neoplasm of vagina
C51.0 Malignant neoplasm of labium majus
C51.1 Malignant neoplasm of labium minus
C51.2 Malignant neoplasm of clitoris
C51.9 Malignant neoplasm of vulva, unspecified
C57.7 Malignant neoplasm of other specified female genital organs
C57.8 Malignant neoplasm of overlapping sites of female genital organs
C57.9 Malignant neoplasm of female genital organ, unspecified
D25.0 Uterine leiomyoma, submucous leiomyoma of uterus
D25.1 Uterine leiomyoma, intramural leiomyoma of uterus
D25.2 Uterine leiomyoma, subserous leiomyoma of uterus
D25.9 Uterine leiomyoma, leiomyoma of uterus, unspecified
D26.0 Other benign neoplasm of uterus, cervix uteri
D26.1 Other benign neoplasm of uterus, corpus uteri
D06.9 Carcinoma in situ of cervix, unspecified
D07.0 Carcinoma in situ of endometrium
D07.30 Carcinoma in situ of unspecified female genital organ
D07.2 Carcinoma in situ of vagina
D07.1 Carcinoma in situ of vulva
D07.39 Carcinoma in situ of other female genital organs
N70.01, .02, .03 Acute salpingitis and oophoritis
N70.11, .12, .13 Chronic salpingitis and oophoritis
N70.91, .92, .93 Salpingitis and oophoritis, unspecified
N73.0 Acute parametritis and pelvic cellulitis
N73.1 or .2 Chronic or unspecified parametritis and pelvic cellulitis
N73.3 Acute pelvic peritonitis, female
N73.4 Chronic pelvic peritonitis, female
N73.6 Pelvic peritoneal adhesions, female (postinfective)
N73.8 Other specified female pelvic inflammatory diseases
N73.9 Female pelvic inflammatory disease, unspecified
N71.0 Acute inflammatory diseases of uterus
N71.1 Chronic inflammatory diseases of uterus
N71.9 Inflammatory diseases of uterus, unspecified
N72 Inflammatory disease of cervix, vagina and vulva, cervicitis and endocervicitis
N76.0, .1, .2, or .3 Other inflammation of vagina and vulva (see book for description)
N77.1 Vaginitis, vulvitis and vulvovaginitis in diseases classified elsewhere
N76.4 Abscess of vulva
N76.6 Ulceration of vulva
N77.0 Ulceration of vulva in diseases classified elsewhere
N76.81 Mucositis (ulcerative) of vagina and vulva
N75.9, N76.5, N76.89 Disease of Bartholin’s gland, ulceration of vagina, or other specified inflammation of vagina and vulva
N84.0 Polyp of corpus uteri
N85.00 Endometrial hyperplasia, unspecified
N85.01 Benign endometrial hyperplasia
N85.02 Endometrial intraepithelial neoplasia (Endometrial Hyperplasia with atypia
N85.8 Other specified noninflammatory disorders of uterus
N85.9 Noninflammatory disorder of uterus, unspecified
N86 Erosion and ectropion of cervix uteri
N87.9 Dysplasia of cervix uteri, unspecified
N87.0 Mild cervical dysplasia
N87.1 Moderate cervical dysplasia
N88.0 Leukoplakia of cervix (uteri)
N84.1 Polyp of cervix uteri
N88.8 Other specified noninflammatory disorders of cervix
N89.3 Dysplasia of vagina, unspecified
N89.4 Leukoplakia of vagina
N89.8 Other specified noninflammatory disorders of vagina
N89.9 Noninflammatory disorders of vagina, unspecified
N84.2 Polyp of vagina
N92.0 Excessive or frequent menstruation
N92.5 Other specified irregular menstruation
N93.8 Other specified abnormal uterine and vaginal bleeding
N92.4 Excessive bleeding in the premenopausal period
N95.0 Postmenopausal bleeding
N95.2 Postmenopausal atrophic vaginitis
R87.619 Unspecified abnormal cytological findings in specimens from cervix uteri
R87.610 Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)
R87.611 Papanicolaou smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)
R87.612 Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL)
R87.613 Papanicolaou smear of cervix with high grade squamous intraepithelial lesion (HGSIL)
R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive
R87.614 Papanicolaou smear of cervix with cytologic evidence of malignancy
R87.616 Satisfactory cervical smear but lacking transformation zone
R87.615 Unsatisfactory cervical cytology smear
R87.820 Other abnormal Papanicolaou smear of cervix and cervical HPV
R87.628 Other abnormal cytological findings on specimens from vagina
R87.620 Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US)
R87.621 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina  (ASC-H)
R87.622 Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)
R.87.623 High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)
R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive
R87.624 Cytologic evidence of malignancy on smear of vagina
R87.625 Unsatisfactory vaginal cytology smear
R87.628 Other abnormal cytological findings on specimens from vagina