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Date Printed: September 25, 2016: 03:13 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2016, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-56000-15

Original Effective Date: 04/15/02

Reviewed: 04/30/09

Revised: 11/01/15

Subject: Cervicography

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Cervicography consists of the use of a specialized camera to take standardized images of the cervix after application of acetic acid. The device is described as easy to use and does not require experience in colposcopy. The photographs, referred to as cervigramsTM, are static photographic images of the cervix similar to those seen during low-level magnification colposcopy. The images are sent to a central laboratory (National Testing Laboratories, the worldwide exclusive licensee of the product) for interpretation by colposcopists who have received specialized training in interpretation of cervigrams. Cervigrams are interpreted as negative, atypical, positive, or defective.

POSITION STATEMENT:

Cervicography is considered experimental or investigational as there is insufficient evidence to recommend for or against routine screening with cervicography. There are no published clinical guidelines from the American College of Obstetricians and Gynecologists, U.S. Preventive Services Task Force (USPSTF) or the American Cancer Society and the American Society of Colposcopy and Cervical Pathology (ASCCP) that recommend the use of cervicography.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code to report cervicography.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Speculoscopy, 02-56000-28

OTHER:

Index terms:

Cervigram (cervicography photographs)

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ). Screening for Cervical Cancer, accessed 02/15/06.
  2. Apgar BS, Brotzman G. HPV Testing in the Evaluation of the Minimally Abnormal Papanicolaou Smear. American Family Physician 1999; 59 (10): 2794.
  3. Blue Cross Blue Shield Association Medical Policy. Cervicography (2.04.04), 05/08/08.
  4. Bomfim-Hyppolito S, Franco ES, Franco RG et al. Cervicography as an adjunctive test to visual inspection with acetic acid in cervical cancer detection screening. International Journal of Gynecology and Obstetrics 2006; 92(1): 58-63.
  5. ECRI Custom Hotline Response. Cervicography for Cervical Cancer Screening, 09/02/05.
  6. Ferris, DG, Schiffman M, Litaker MS et al. Cervicography for Triage of Women with Mildly Abnormal Cervical Cytology Results. American Journal of Obstetrics and Gynecology 2001; 185(4): 939-943.
  7. Howard M, Sellors JW, Lytwyn A et al. Combining human papillomavirus testing or cervicography with cytology to detect cervical neoplasia. Archives of Pathology and Laboratory Medicine 2004; 128: 1257-1262.
  8. U.S. Preventive Services Task Force Screening for Cervical Cancer 01/03. Accessed 02/26/08.
  9. Wright TC, Denny L, Kuhn L et al. HPV DNA Testing of Self-Collected Vaginal Samples Compared with Cytologic Screening to Detect Cervical Cancer. The Journal of the American Medical Association 2000; 283 (1): 81-86.
  10. Wright TC, Massad S, Dunton CJ et al. 2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Cancer Screening Tests. American Journal of Obstetrics & Gynecology 2007: 346-355.
  11. Wright, TC, Cox T, Massad L, et al. 2001 Consensus Guideline for the Management of Women with Cervical Cytological Abnormalities. The Journal of the American Medical Association 2002; 287(16): 2120-2129.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/30/09.

GUIDELINE UPDATE INFORMATION:

01/01/02

Updated to include new CPT code.

04/15/02

Medical Coverage Guideline reviewed and reformatted.

05/15/03

Annual review.

06/15/04

Scheduled review, no revisions.

03/15/05

Scheduled review, no change in coverage statement. Updated references.

04/15/06

Annual review, no change in coverage. Updated references.

04/15/07

Scheduled review. No change in coverage statement.

06/15/07

Reformatted guideline.

04/15/08

Scheduled review. No change in position statement. Delete 0003T. Updated references.

05/15/09

Annual review. No change in position statement. Updated references.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: September 25, 2016: 03:13 AM