Oncology & Hematology Coding Alert

Link the right ICD-9 code to 84153

The next time the oncologist uses diagnostic prostate specific antigen (PSA) tests to examine a postoperative prostate cancer patient, don't rely on ICD-9 code 600.00 to satisfy Medicare. Instead, use signs and symptoms coding for medical justification.
 
Symptoms indicate to the insurer that the oncologist performed a diagnostic test, says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa. 
 
Oncologists and other physicians use PSA tests (84153, Prostate specific antigen; total) as a tumor marker to detect recurrent cancer following radiation therapy or tumor removal, such as a radical prostatectomy (52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).

Support Your Claim With Physician Documentation

Effective Oct. 1, CMS excluded 600.00 (Hypertrophy [benign] of prostate without urinary obstruction) (BPH) from a National Coverage Determination that listed appropriate diagnosis codes for PSA tests. Previously, many states allowed a diagnostic PSA (84153) for BPH. But the new national guidelines for Medicare carriers replace local medical review policies (LMRPs), Wolfgang says.
 
Coders should rely on physician documentation when reporting PSA tests for BPH patients. Most men who present to the oncologist with BPH have urinary retention (788.20), frequency (788.41), nocturia (788.43) or reduced urine stream (788.62) - and Medicare accepts all of these ICD-9 codes, says Robert Murray, PhD, director of technology at Midwest Diagnostic Pathology in Park Ridge, Ill., and member of the NCD negotiated rulemaking committee.
 
For instance, your oncologist performs a PSA test on a patient who recently underwent chemotherapy. The physician notes urinary frequency and hematuria, along with history of prostate cancer. Therefore, to support medical necessity, you could report signs and symptoms, such as 788.41 (... frequency) and 599.7 (Hematuria). Also, as a secondary diagnosis, list V10.46 (Personal history of malignant neoplasm; prostate).

Provide Oncologist With ICD-9 List

Make sure you educate your oncologist about the importance of listing signs and symptoms leading to the PSA assessment. You can't use symptom codes if the oncologist doesn't note them.
 
"The solution is physician education," Murray says. Inform clients that Medicare no longer accepts BPH (600.00) for diagnostic PSA and provide the list of covered diagnoses for their referral.
 
Consider providing your physician with a list of diagnosis codes that Medicare accepts for PSA tests. (See "PSA Testing: Know Which ICD-9 Codes to Use" on page 92 for a list of approved ICD-9 codes).
 
Note: View the NCD at http://www.cms.gov/mcd/viewncd.asp?ncd_id=4020&ncd_version=2&basket=ncd%3A40%2D20%3A2%3AProstate+Specific+Antigen).