Anthem Central Region Clinical Claims Edit
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- Vanessa Lang
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1 Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Cytopathology, Cervical or Vaginal with Evaluation and Management Services Edit #: 299 Effective Date: 8/7/ /31/2099 Status: Current Last Review Date: 4/9/2009 Edit (Cytopathology, cervical or vaginal {any reporting system}; requiring interpretation by physician {list separately in addition to code for technical service), (Cytopathology, cervical or vaginal {any reporting system}, collected in preservation fluid, automated thin layer preparation; manual screening under physician supervision) (Cytopathology, cervical or vaginal {any reporting system; with manual screening and rescreening under physician supervision), (Cytopathology, smears, cervical or vaginal; screening by automated system under physician supervision), (Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal; manual screening under physician supervision), (Cytopathology, slides, cervical or vaginal; with manual screening and computerassisted rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision), (Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation {e.g., maturation index, karyopyknotic index, estrogenic index} {List separately in addition to code(s) for other technical and interpretation services}), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; manual screening under physician supervision), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer assisted rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer-assisted rescreening using cell selection and review with physician supervision), (Cytopathology, cervical or vaginal {any reporting system}, collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision) and (Cytopathology, cervical or vaginal {any reporting system}, collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision) bundles with , , , 99318, , , and (Outpatient services, nursing facility services, domiciliary/rest home/boarding home or custodial care services, home services, preventive medicine services and special evaluation and management services). Page 1 of 6
2 CODE RULE CODE Redundant/Mutually Exclusive Page 2 of 6
3 Rationale for Edit: Anthem Central Region bundles , , as redundant/mutually exclusive with , , , 99318, , , or In most cases when a family physician, internist or obstetrician/gynecologist submits a cytopathology/pap smear code they are not the physicians preparing and/or interpreting the pap smear, they are the physicians who obtained the specimen. A pathologist preparing and interpreting and writing the report of the cytopathology/pap smear must bill for this service. If , or is submitted with evaluation and management services , , , 99318, , , or only the evaluation and management service will reimburse. A pathologist should submit for the cytopathology/pap smear service ( , or Prior Version(s), if any, of this edit can be found below Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Page 3 of 6
4 Subject: Cytopathology, Cervical or Vaginal with Evaluation and Management Services Edit #: 299 Effective Date: 12/31/2001-8/6/2009 Status: Prior Last Review Date: 09/20/2001 Edit (Cytopathology, cervical or vaginal {any reporting system}; requiring interpretation by physician {list separately in addition to code for technical service), (Cytopathology, cervical or vaginal {any reporting system}, collected in preservation fluid, automated thin layer preparation; manual screening under physician supervision) (Cytopathology, cervical or vaginal {any reporting system; with manual screening and rescreening under physician supervision), (Cytopathology, smears, cervical or vaginal; screening by automated system under physician supervision), (Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal; manual screening under physician supervision), (Cytopathology, slides, cervical or vaginal; with manual screening and computerassisted rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision), (Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation {e.g., maturation index, karyopyknotic index, estrogenic index} {List separately in addition to code(s) for other technical and interpretation services}), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; manual screening under physician supervision), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer assisted rescreening under physician supervision), (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer-assisted rescreening using cell selection and review with physician supervision), (Cytopathology, cervical or vaginal {any reporting system}, collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision) and (Cytopathology, cervical or vaginal {any reporting system}, collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision) bundles with , , , , , , and outpatient services, nursing facility services, domiciliary/rest home/boarding home or custodial care services, home services, preventive medicine services and special (Evaluation and management services). CODE RULE CODE Redundant/Mutually Page 4 of 6
5 Exclusive Page 5 of 6
6 Rationale for Edit: Anthem Central Region bundles , , as redundant/mutually exclusive with , , , , , , or In most cases when a family physician, internist or obstetrician/gynecologist submits a cytopathology/pap smear code they are not the physicians preparing and/or interpreting the pap smear, they are the physicians who obtained the specimen. A pathologist preparing and interpreting the cytopathology/pap smear must bill for this service. Anthem does not reimburse for cytopathology/pap smears when submitted by any other type of provider than a pathologist. but will make the cytopathology/pap smear service incidental or a visit edit to some evaluation and management services. If , or is submitted with evaluation and management services , , , , , , or only the evaluation and management service will reimburse. A pathologist should submit for the cytopathology/pap smear service ( , or Page 6 of 6
Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit
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1 Screening Mammogram (Bilateral); including CAD Service CPT Code 77067 77067-TC 77067-26 $111.40 $81.32 $30.08 $131.51 $93.70 $37.82 * Note: Breast tomosynthesis, unilateral (77061) and bilateral (77062)
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