Currentpriority healthPolicy N/A

Cervical Cancer Screening Billing Policy

Defines Priority Health's billing, coding, documentation, place-of-service, and reimbursement guidance for cervical cancer screening (Pap and HPV testing) for providers submitting claims under member benefit plans.

Policy Summary

Payerpriority health

PolicyCervical Cancer Screening Billing Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor Medicare, obtain a Pre-Service Organization Determination (PSOD) when indications do not meet NCD, local LCD, or specific medical policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30+referenced codes

USPSTFclinical source

5required record elements

requiredMedicare PSOD

Coverage and Billing Rules

Coverage criteria and billing rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Inclusion of a code in this policy does not imply covered status; benefit coverage is determined by the member's specific benefit plan document and applicable laws.

Priority Health follows USPSTF recommendations for cervical cancer screening; where CMS or MDHHS guidance applies it supersedes unless otherwise specified.

Listing of procedure codes is provided for reference only and is not all‑inclusive; inclusion of a code does not imply any right to reimbursement or guarantee claim payment.

Molecular pathology procedures (81161, 81200-81408) should not be reported in combination with, or instead of, infectious agent detection by nucleic acid procedures (87471-87801).

Report 87624 for a singular pooled high‑risk HPV result; for separate reporting of more than four high‑risk types see 87626.

G0476 (HPV high‑risk for cervical cancer screening) must be performed in addition to Pap test for cervical cancer screening when following CMS guidance.

Documentation requirements: medical records must document reason for screening, screening results, follow‑up/additional services, specimen collection details, and slide preparation. Orders must be signed and dated; routine protocol‑based orders require supporting documentation to be payable.

Place of service and authorization: coverage considered for services furnished in an appropriate setting to the patient's needs; authorization may be required and does not guarantee payment.

For Medicare indications that do not meet NCD, local LCD or specific medical policy, a Pre‑Service Organization Determination (PSOD) is required.

Apply modifiers per standard billing/CMS NCCI guidance; incorrect modifier use or failure to follow coding/billing requirements may result in denials, recoupment, or claim rejection.

Reimbursement rates are available via standard fee schedules for the contract (login required); Priority Health may perform pre‑ or post‑claim reviews to validate billing and coding accuracy.

Referenced Procedure and Test Codes

Referenced HPV CPT/HCPCS and Cytology Codesmixed

87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44)
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68), pooled result
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed
87626	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52) and high-risk pooled result(s)
88141	Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician Report 88141 in addition 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164-88167, 88174 and 88175.
88142	Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision
G0476	Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test

HPV testing combination

CMS co-testing requirementG0476 (HPV, high-risk types) must be performed in addition to a Pap test for cervical cancer screening per CMS guidance.

Related guidance on molecular testingMolecular pathology procedures (81161, 81200-81408) should not be reported in combination with, or instead of, infectious agent detection by nucleic acid procedures (87471-87801).

Reporting pooled resultsReport 87624 for a singular pooled high-risk HPV result or when both low-risk and high-risk types are performed in a single assay.

Separate reporting for multiple typesFor HPV detection of more than four high‑risk types reported separately, see 87626.

Authorization and Provider Requirements

Prior Authorization

Medicare Pre-Service Organization Determination (PSOD) Required

For Medicare: For indications that do not meet criteria of an NCD, local LCD, or specific medical policy, a Pre-Service Organization Determination (PSOD) is required. Providers should submit a PSOD request when coverage is being sought for services not clearly supported by NCD/LCD criteria.

Medicare PSOD required when indication does not meet NCD/LCD or specific medical policy
Include clinical documentation supporting medical necessity with the PSOD request
Click here for additional details on PSOD (provider portal/resource)

Prior Authorization

Place of Service and Authorization

Place of Service: Coverage will be considered for services furnished in the appropriate setting to the patient's medical needs and condition. Authorization may be required — verify site-of-service and submit any required authorization prior to service.

Confirm appropriate Place of Service on claims and authorization requests
Obtain prior authorization when required by the member's benefit plan

Documentation Required

Documentation, Billing, and Disclaimer

Provider responsibilities and disclaimer: CMS and/or MDHHS guidelines apply unless otherwise specified. Authorization requirements do not guarantee payment — proper billing, coding, and documentation consistent with CPT, HCPCS, revenue codes, CMS and MDHHS guidance are required. Failure to follow guidelines may result in claim denial, recoupment, or rejection.

An authorization is not a guarantee of payment; submit fully documented, correctly coded claims
Priority Health may deny, recoup, or reject claims if regulatory, policy, or contractual requirements are not met
Retain clinical documentation supporting services and make available upon request for pre- or post-claim review

Key Definitions

HPV test

DefinitionA test to detect human papillomavirus (HPV), the virus that can cause cervical cell changes and is used in cervical cancer screening.

PurposeIdentifies presence of high‑risk and/or low‑risk HPV types associated with cervical precancer and cancer.

Use in screeningPerformed alone or with a Pap test (co‑testing) to screen for precancerous cervical changes or early cancer.

Pap test

DefinitionCytologic examination of cervical cells (Pap test or Pap smear) to detect precancerous cell changes on the cervix.

Role in screeningUsed alone or with HPV testing (co‑testing) to identify cells that may progress to cervical cancer if untreated.

Billing notePap tests requiring physician interpretation should be coded appropriately; negative smears not requiring physician interpretation should not be coded with 88141.