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)