Oncology & Hematology Coding Alert
Biopsy Isn't Mandatory To Diagnose Cancer
Question: In an elderly patient, who showed signs of bone metastasis, our physician wants to avoid a prostate biopsy. The patient has very high PS levels which are indicative of prostate cancer. Our physician has chosen Lupron as the next plan of therapy for this patient. Medicare may not cover Lupron without a diagnosis of prostate cancer. Is it mandatory to do a biopsy to be able to submit a diagnosis of prostate cancer?
New York Subscriber
Answer: A biopsy is not necessary for your physician to document a diagnosis of cancer if the symptoms, observations and/or diagnostic findings lead to the clinical judgement diagnosis of prostate cancer. If the physician can make the clinical diagnosis of carcinoma of the prostate (185, Malignant neoplasm of prostate), you may bill for the Lupron with a diagnosis of prostate cancer. When ICD-10-CM is effective, you will submit code C61 (Malignant neoplasm of prostate).
Oncology & Hematology Coding Alert
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