Oncology & Hematology Coding Alert

Question: What are the rules for coding prostate cancer screenings? Can we report E/M services in addition to screenings, or are E/Ms considered included in codes G0102 and G0103? Does appending modifier -25 to the E/M make a difference?

Iowa Subscriber
 
Answer: When a Medicare patient presents only for a prostate screening, report two codes - one HCPCS and one ICD-9. Specifically, you must link the diagnosis code V76.44 (Special screening; prostate) to one of Medicare's two HCPCS codes, G0102 (Prostate cancer screening; digital rectal examination) and G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total) depending on the type of screening the physician performed.
 
When reporting prostate screenings, you should not report additional E/M services unless your physician performs an E/M service for an entirely different problem that is represented in a separate diagnosis code linked to the E/M code. For this case, your E/M service will include the digital rectal exam, and code G0102 should never be billed in addition to the exam. Do not use the ICD-9 diagnosis code V76.44 with any E/M service or code. Medicare doesn't require modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when billing an E/M service and code G0103 for a screening PSA. But CMS mandates that you assign V76.44 with G0103.