□ PAP

Transcription

□ PAP
8/1/2013a
WOMEN’S HEALTH
TEST REQUISITION
OFFICE
A signed ABN must also be attached for Medicare Screening Paps.
Submitting Clinician:
Office Location:
Name: (Last) ________________________________ (First) ____________________ (Middle) ________________________
PATIENT
Date of Birth _________________ Age __________ SSN**_________________________ PT ID# ______________________
Responsible Party (if Minor) _____________________________________ Responsible Party SSN _____________________
Patient Address ________________________________________________________________________________________
□ Thin Prep Vial
□ Swab
□ Urine Container
PAP
□
□
□
SOURCE
TYPE
COLLECTION
DATE
SPECIMEN
City ________________________________ State ____________ Zip code ___________ Phone ______________________
Please attach a printout of information from your EMR if available.
** We are a covered entity under HIPAA regulations. SSN’s are used to aid in linking patient history for optimal patient care.
ICD9 Code(s) *
Screening Pap (Low Risk Patient)
Screening Pap (High Risk Patient)
Diagnostic Pap
Must be in conjunction with recent Pap (FDA)
To Determine Presence of types 16 & /or 18
_____________
_____________
_____________
_____________
ASCCP Guideline
GC/CHLAMYDIA/TRICH (check boxes)
□
□
□
Chlamydia (CT) rRNA Assay
Gonorrhea (GC) rRNA Assay
_____________
_____________
Trichomonas (Trich) rRNA Asssay
_____________
□
_______________________________
_____________
OTHER
CLINICAL HISTORY
TESTS ORDERED
May be used for over 30 screen.
□ Cervix/Endocervix
□ ____________________
LMP___________________________
____________
____________
____________
HPV High Risk Screening/Subtyping
□ HPV Regardless of Pap Result
□ Reflexive Screen for HPV (check one or more)
□ if ASCUS
□ if ASC-H
□ if Low Grade □ if High Grade
□ if any abnormal
□ HPV Screening only
□ HPV Subtyping (check either or both)
□ on Postive HPV if Pap Normal
□ on all Positive HPV Screens
□ Vagina
□ Urine
□ Routine Exam
□ Abnormal Exam (HPV, lesion) *
□ Abnormal Bleeding
□ Contraceptive: type _______________
□ Estrogen Therapy
□ Post Menopausal
□ Pregnant _____ weeks
□ Post Partum ____ weeks
□ Hx of Abnormal Pap
□ Hysterectomy—total
□ Hysterectomy, intact cervix
□ Hx of malignancy; Rx, surgery *
□ Pelvic Radiation *
□ Other high-risk factors *
* Please explain item if checked:
__________________________________
__________________________________
* A reference list of ICD-9 codes is shown on the back of this form. Please refer to an ICD-9 manual
for a complete list and authoritative information. The ordering practitioner is ultimately responsible for
providing medically appropriate ICD-9 codes based on the patient’s signs and symptoms.
__________________________________
Primary INS ____________________________________________________________________________________________
INSURANCE
Claims Address _________________________________________________________________________________________
Insured’s Name ___________________________________
Policy/Member # ______________________________________
Insured’s DOB ____________________________________
Group #/Employer_____________________________________
Insured’s SSN ____________________________________
MEDICARE #_________________________________________
Insured’s Relation to Patient _________________________
Medicaid # __________________________________________
Secondary INS ______________________________________________
Please attach a copy of each insurance card.
CASE #
LABEL
For SEP Use Only
8/1/2013a
ICD-9 SCREENING CODES
MEDICARE1
1
V15.89
V22.0
V22.1
M-H
N
N
Screening other specified personal history presenting hazards to health 2
Supervision of normal first pregnancy
Supervision of other normal pregnancy
V22.2
N
Pregnant state, incidental
V24.2
N
Postpartum (routine postpartum follow-up)
V25.49
V69.8
V72.31
V72.32
N
M-H
M-L
N
V73.81
N
Special screening exam for human papillomavirus (HPV)
V73.88
V73.98
V74.5
N
N
N
Special screening exam for other specified chlamydial diseases
Special screening exam for unspecified chlamydial disease
Special screening exam for sexually transmitted diseases NOS
V76.2
M-L
Screening for malignant neoplasms of the cervix
V76.47
V76.49
M-L
M-L
Screening for malignant neoplasms of the vagina (post-hysterectomy for non-malignant conditions)
Screening for malignant neoplasms of other sites
Surveillance of previously prescribed contraceptive methods, other contraceptive method
Other problems related to lifestyle
Routine gynecological exam with or without Pap test
Encounter for Pap cervical smear to confirm findings of recent normal smear following initial abnormal smear
M-H This is an allowable code for MEDICARE– High Risk. ABN required for Medicare Screening Paps.
Can be repeated after 11 months (Medicare)
M-L This is an allowable code for MEDICARE– Low Risk. ABN required for Medicare Screening Paps. Can be repeated at 2 years (Medicare)
N This code is not covered for Medicare Screening Paps
COMMON ICD-9 DIAGNOSTIC CODES
2
MEDICARE DEFINES HIGH RISK FOR CERVICAL CANCER AS:
▪ Early onset of sexual activity—before age 16
▪ Fewer than 3 negative Paps in the past 7 years
054.19
054.9
079.4
112.1
131.01
131.09
182.0
183.0
233.1
233.2
616.0
616.10
617.0
622.10
622.11
622.12
623.5
623.8
626.0
626.2
626.4
626.6
626.8
627.1
627.3
795.00
795.01
795.02
795.03
795.04
795.05
795.06
795.07
795.08
795.09
▪ Multiple sex partners (5 or more in a lifetime)
▪ History of any STD’s
▪ Daughter of a mother who took DES during pregnancy
Genital herpes
Herpes simplex without mention of complication
HPV (human papillomavirus)
Candidiasis of vulva and vagina
Trichomonial vulvovaginitis
Trichomoniasis, Other
Malignant neoplasm of body of uterus, corpus uteri / Endometrium / Myometrium /Fundus
Malignant neoplasm of ovary and other uterine adnexa
Carcinoma in situ of breast and genitourinary system, cervix uteri
Carcinoma in situ of breast and genitourinary system, other and unspecified parts of uterus
Inflammatory disease of cervix, vagina and vulva, cervicitis and endocervicitis
Inflammatory disease of cervix, vagina and vulva, vaginitis and vulvovaginitis
Endometriosis of uterus
Cervical intraepithelial neoplasia (CIN), unspecified dysplasia, with histologic confirmation
Cervical intraepithelial neoplasia (CIN I), mild dysplasia, with histologic confirmation
Cervical intraepithelial neoplasia (CIN II), moderate dysplasia, with histologic confirmation
Vaginal discharge not otherwise specified
Noninflammatory disorders of vagina (e.g. cyst of vagina, hemorrhage of vagina)
Absence of menstruation (amenorrhea)
Excessive or frequent menstruation (e.g. menorrhagia, menometrorrhagia, heavy periods)
Irregular menstrual cycle (bleeding not otherwise specified)
Metrorrhagia (bleeding unrelated to menstrual cycle or irregular intermenstrual bleeding)
Dysfunctional or functional uterine hemorrhage NOS
Postmenopausal bleeding
Postmenopausal atrophic vaginitis
Abnormal glandular Pap smear of cervix not otherwise specified
Abnormal Pap smear of cervix with ASC-US (atypical squamous cells of undetermined significance)
Abnormal Pap smear of cervix with ASC-US cannot exclude high grade (ASC-H)
Abnormal Pap smear of cervix with low grade squamous intraepithelial lesion (LGSIL)
Abnormal Pap smear of cervix with high grade squamous intraepithelial lesion (HGSIL)
Cervical high risk HPV test POSITIVE
Papanicolaou smear of cervix with cytologic evidence of malignancy
Satisfactory cervical smear but lacking transformation zone
Unsatisfactory cervical cytology smear (inadequate cervical cytology sample)
Cervical low risk HPV test POSITIVE (use also 079.4)
This is alist of the ICD-9 codes most commonly received by SouthEastern Pathology for this type of test. Please refer to an ICD-9 manual for a
complete list and authoritative information. The ordering physician or practitioner is ultimately responsible for providing medically appropriate
ICD-9 codes based on the patient’s signs and symptoms.
Clinicians are reminded that tests for which Medicare reimbursement will be sought should only be ordered if medically necessary
for the diagnosis and treatment of the patient rather than for screening purposes, except for those screening tests which have been specifically listed
as covered by Medicare.