Gastroenterology Coding Alert

Question: Does Medicare cover screening tests for prostate cancer? If so, what codes do we use to report the tests?

Texas Subscriber

Answer: Effective Jan. 1, 2000, Medicare provides coverage of two screening tests for prostate cancer: the digital rectal exam (DRE) and the prostate specific antigen (PSA) test. These services are available to male beneficiaries aged 50 and older and can be performed every 12 months. Both tests can be done within the same one-year period.

A DRE is a clinical examination of an individuals prostate for nodules or other abnormalities. Gastroenterologists should use G0102 (prostate cancer screening; digital rectal exam) to report this service. Reimbursement for the test will be the same as the lowest level evaluation and management service (99211, office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).

The second benefit, the PSA blood test, detects the marker for adenocarcinoma of the prostate. For purposes of screening asymptomatic patients, Medicare has designated that G0103 (prostate cancer screening; PSA test) be used. Although the laboratory that processes the PSA blood test usually will bill this code, a gastroenterologist can use G0001 (routine venipuncture for collection of specimens[s]) to report the blood draw.

Medicare has not yet established a list of covered ICD-9 codes for the prostate cancer screening tests as it has done with other preventative services. Because Medicare did not specify ICD-9 codes for these tests, there may be some variability among carriers, advises Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the American Medical Associations CPT editorial panel. Gastroenterologists may want to read their local Medicare offices coding guidelines for these services before submitting a claim.

Several states, including Pennsylvania, Illinois, Michigan and Wisconsin, have coding guidelines that stipulate that code V76.44 (special screening for malignant neoplasms, prostate) should be used for both screening tests.