Medicare Compliance & Reimbursement

Question: A 66-year-old male patient was complaining of frequent urination during his annual physical. He also noticed some discoloration and darkening of his urine, and test results showed some trace blood in his urine. He has a history of enlarged prostate, and the physician ordered a prostate-specific antigen (PSA) screening to rule out prostate cancer, which came back within normal limits. What diagnosis code should I use for this encounter? What test code should I report?

AAPC Forum Participant

Answer: Because the patient reported some urinary frequency and hematuria, you’ll report N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms) for this encounter. This code covers both the enlarged prostate and the patient’s urinary symptoms.

Caveat: Had the test results shown an elevated PSA, your diagnosis coding would change to R97.20 (Elevated prostate specific antigen (PSA)). If the provider specifically diagnosed prostate cancer, you would report C61 (Malignant neoplasm of prostate).

PSA clarification: The physician ordered a diagnostic PSA test to rule out or diagnose prostate cancer. This test measures the amount of PSA in the patient’s blood, and elevated levels can indicate cancer, so you should choose one of these three diagnostic test codes to report:

• 84152 (Prostate specific antigen (PSA); complexed (direct measurement))
• 84153 (... total)
• 84154 (... free)

The complexed, or direct measurement PSA, measures the amount of PSA that is attached to blood proteins. The free diagnostic screening measures how much PSA freely circulates unattached to blood proteins. However, the most common is the total screening, which measures both attached and unattached. Be sure to check the physician’s documentation to determine which they ordered to ensure you choose the correct code.

Watch out: For Medicare beneficiaries, there is a preventive medicine screening for prostate cancer. Male patients over 50 years of age are allowed a screening PSA and digital rectal exam to check for prostate cancer every 12 months. For these cases, report HCPCS Level II code G0102 (Prostate cancer screening; digital rectal examination) or G0103 (… prostate specific antigen test (PSA)).