CPT Code 99213 for Routine Pap Smear Visits
CPT code 99213 should not be used as the primary billing code for a routine, preventive Pap smear visit in a healthy woman with no abnormal history, as this is a preventive service that requires a preventive medicine service code (99381-99397 series) instead. 1
Understanding the Coding Distinction
The fundamental issue here is distinguishing between preventive services and problem-oriented evaluation and management (E&M) services:
99213 is an established patient office visit code used for problem-oriented encounters where the patient presents with symptoms, concerns, or medical problems requiring evaluation and management 2
Routine Pap smears are preventive services performed for cervical cancer screening in asymptomatic women, which fall under preventive medicine service codes (99391-99397 for established patients, 99381-99387 for new patients) 1, 3
When 99213 Would Be Appropriate
You can use 99213 for a Pap smear visit only when:
The patient presents with specific gynecological symptoms (vaginal discharge, abnormal bleeding, pelvic pain) that require evaluation beyond routine screening 4, 5
The visit involves management of abnormal previous Pap results requiring follow-up evaluation 6
There is documented medical decision-making for a problem separate from the screening itself 2
Common Billing Pitfall
A critical caveat: Many residency clinics and primary care practices significantly undercode their services, with studies showing 72.1% of visits coded as 99213 or lower could have been billed at higher levels when additional problems were addressed 2. However, this undercoding issue applies to problem-oriented visits, not pure preventive services.
The Correct Approach for Routine Screening
For your scenario (routine Pap smear, no previous abnormalities, asymptomatic patient):
Use preventive medicine codes (99391-99397 based on patient age) as the primary code 1, 3
The Pap smear collection itself may be separately billable depending on payer policies
If a problem is identified and addressed during the same visit, you may be able to bill both a preventive code and a problem-oriented E&M code (like 99213) with modifier -25, but documentation must clearly support both services 2
Documentation Requirements
If you attempt to bill 99213 alongside preventive services, you must document:
The separate, identifiable problem that required evaluation beyond screening 2
Medical decision-making specific to that problem
That the problem-oriented service was significant and separately identifiable from the preventive service
Without these elements clearly documented, using 99213 for a routine screening visit would be inappropriate coding and could constitute billing fraud.