by Jared Staheli
June 26th, 2015
The following requirements must be met.
1. The beneficiary has not had a screening Pap smear test during the preceding three years (i.e., 35 months have passed following the month that the woman had the last covered Pap smear. Use one of the following ICD-9-CM codes V76.2, V76.47, or V76.49; or
2. There is evidence (on the basis of her medical history or other findings) that she is of childbearing age and has had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding 3 years; and at least 11 months have passed following the month that the last covered Pap smear was performed; or
3. She is at high risk of developing cervical or vaginal cancer (use ICD-9-CM code V15.89, other specified personal history presenting hazards to health) and at least 11 months have passed following the month that the last covered screening Pap smear was performed. The high risk factors for cervical and vaginal cancer are:
a. Cervical Cancer High Risk Factors:
• Early onset of sexual activity (under 16 years of age)
• Multiple sexual partners (5 or more in a lifetime)
• History of a sexually transmitted disease (including HIV infection)
• Fewer than three negative or any Pap smears within the previous 7 years
b. Vaginal Cancer High Risk Factors:
• DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy.
NOTE: The term “woman of childbearing age” means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other findings.
COUNTING: To determine the 11-, 23-, and 35-month periods, start counts beginning with the month after the month in which a previous test/procedure was performed.
COUNTING EXAMPLE: A beneficiary identified as being at high risk for developing cervical cancer received a screening Pap smear in January 2000. Start counts beginning with February 2000. The beneficiary is eligible to receive another screening Pap smear in January 2001 (the month after 11 full months have passed).
If the beneficiary does not qualify for more frequent screening based on paragraphs (2) and (3) above, for services performed on or after July 1, 2001, payment may be made for a screening PAP smear after 23 months have passed after the end of the month of the last covered smear. All other coverage and payment requirements remain the same.