Oncology & Hematology Coding Alert

Heads up: CMS considers urological signs or symptoms payable diagnoses for PSA determinations.

So you may know your oncologist may utilize prostate specific antigen (PSA) testing for both screening and diagnosis of prostate cancer, but are you aware the diagnosis codes you report will play an important role when submitting claims for this test?

Follow these expert tips to prevent denials of PSA claims. 

Tip 1: Determine Why Test Was Ordered

You have two procedure codes to choose from, and the choice depends on the reason your oncologist ordered the test.

Screening vs diagnosis: You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test [PSA]). Some other payers follow these same guidelines. On the other hand, for a diagnostic PSA test, report 84153 (Prostate specific antigen [PSA]; total).

How do you confirm the diagnostic intent? Reviewing the documentation is the only way to know whether your oncologist intended to perform a screening or a diagnostic PSA test.

To qualify for a screening PSA, the patient record should state they never had a prostate cancer diagnosis. A PSA screening test can be performed on an annual basis. On the other hand, there isn’t any time restriction for the diagnostic PSA. Your physician can do PSA testing based on medical necessity for the purpose of diagnosis of the state of a current condition. “When the test is performed for diagnostic purposes, valid diagnoses for coverage may range from a known condition to determine the status of the disease or for various signs and symptoms,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC. “CMS has a national coverage determination (NCD) policy explaining the limitations of coverage for both diagnostic and screening purposes.” See Medicare Publication 100-03: National Coverage Determination (NCD) for Prostate Specific Antigen (190.31).

Tip 2: Match Diagnosis to Reason

You should report a screening test for a patient with no signs or symptoms of disease using diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate), which properly describes the reason for the test.

If you reported a different diagnosis code with G0103, Medicare will deny the claim. Usually, Z12.5 is the only ICD-10-CM code Medicare will allow for a screening PSA. If the physician suspects something else, the correct coding of the test may be a diagnostic PSA.

Official word: CMS’s Medicare Claims Processing Manual, Chapter 18 - Preventive and Screening Services guides you on this requirement: “Prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using screening (‘Z’) code Z12.5.”

When diagnostic PSA is the result and should the documentation indicate an elevated PSA, you should report R97.2 (Elevated prostate specific antigen [PSA]) as the diagnosis.

Normal results and documentation of an enlarged prostate require one of the following benign prostatic hyperplasia (BPH) codes:

• N40.0 (Benign prostatic hyperplasia without lower urinary tract symptoms)
• N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms).

Alternative: If the oncologist documents a more specific diagnosis, such as prostate cancer, you need to report the appropriate code (C61, Malignant neoplasm of prostate). Where only signs and symptoms are noted, you should report the documented signs and symptoms.

According to the LCDs and the NCD, Medicare considers many ICD-10-CM codes representing urological signs or symptoms payable diagnoses for PSA determinations. For example, R31.0 (Gross hematuria), R31.1 (Benign essential microscopic hematuria), R35.0 (Frequency of micturition), R35.1 (Nocturia), or R39.11 (Hesitancy of micturition) may be the most appropriate supporting ICD-10-CM codes when no confirmed condition or abnormal result is identified.

Check with your payer: Covered diagnoses for a PSA test vary from payer to payer. Payer policies will list covered diagnoses. If you bill any code within this list, you should not face denials. Regardless of coverage medical record, documentation must support your diagnosis choice.

Tip 3: Watch Out for Annual Coding Limits

Medicare only pays for one screening PSA per year. However, Medicare (and other payers) may reimburse you for as many diagnostic PSAs the patient needs, as long as documentation supports medical necessity for more frequent testing.

Watch out: Not only should you check your own practice’s medical record, you should also check whether the patient has had a PSA screening at another office within the last year. You may occasionally find patients who received a screening PSA performed at another doctor’s office, such as their primary care doctor. If screening PSA exceeds an annual frequency, the payer will deny your claim.

Self-pay option: If the patient wants or needs a screening PSA test before the one-year time limit is up, your best bet is to have the patient sign an advance beneficiary notice (ABN) for Medicare or insurance waiver equivalent form for other payors. The forms explain the potential noncoverage and they would have the responsibility to pay for the test should their insurance payer refuse to reimburse the PSA screening earlier than their benefit would allow.