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.
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 Z01.411, Z01.419, 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 Z72.51, Z72.52, Z72.53, Z77.29, Z77.9, Z91.89, Z92.850, Z92.858, and Z92.86 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 |