Oncology & Hematology Coding Alert

With the so-called "graying of America," providers are reporting more prostate studies, but coders must beware: Proper coding of these studies requires all sorts of documentation to determine whether the study is screening or diagnostic.

What follows is a guide to clarify the factors that impact coding so you can ensure optimal payment for your oncology practice.

It's been only two years since Medicare began covering prostate screening exams for beneficiaries. As of January 2000, Medicare instituted payment for digital rectal examinations (DREs) and prostate-specific antigen (PSA) screening studies. Both are recognized as valuable tools for diagnosing cancer early.

CMS policy now allows oncologists to order screening DREs and PSAs once a year when their patients reach 50. Many practices screen patients in their 40s, but these tests for younger patients are simply included with the fees for an office visit. The preventive service codes that should be assigned are 99386 for a new patient, aged 40-64, or 99396 for an established patient aged 40-64. Remember, however, that Medicare does not pay for routine checkups.

You report a DRE with HCPCS code G0102 (Prostate cancer screening; digital rectal exam), says Margie Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans.

G0102 has been assigned the same value as CPT code 99211, the lowest level of evaluation and management service, in the 2002 Physician Fee Schedule. The physician work relative value units (RVUs) assigned to both are 0.17, Hickey says. Medicare policy states that a DRE performed on the same day as a covered E/M service (e.g., problem-focused visit) is bundled into the payment for the E/M care. You should note, however, that if the DRE is the only service provided or is provided as part of an otherwise noncovered service (like code 99397 for a preventive visit), then HCPCS code G0102 is separately payable.

Likewise, a screening PSA is reported to Medicare with G0103 (Prostate cancer screening; prostate specific antigen test, total). As with G0102, you can report a screening PSA to Medicare once a year for men older than 50. However, G0103 is paid under the clinical diagnostic laboratory fee schedule and, as such, is classified with an "X" status on the physician payment schedule. No RVUs are assigned to status-X codes, which are defined as items or services that are not in the statutory definition of "physician services" for fee schedule payment purposes.

CMS policy also reimburses for screening PSAs in younger men who display no symptoms but are considered at high risk for prostate cancer. "Even though the patient may be asymptomatic and has never had a problem himself, family history of prostate cancer would place him in the high-risk category. Perhaps his father, brother or uncle has had prostate cancer, for example," says Dianna Hoffbeck, RN, CCM, HCFE, president of North Shore Medical Inc., in Absecon, New Jersey.

Black males are also high-risk because they have a 34 percent higher incidence rate of prostate cancer than white males and tend to develop a form of very aggressive prostate cancer. In these cases, G0103 may be reported as long as you supply documentation to support the medical necessity of early screening.

The diagnosis code for prostate screening is V76.44 (Special screening for malignant neoplasms; other sites, prostate). When the patient is identified as high-risk because of relatives with prostate cancer, coders add V16.42 (Family history of malignant neoplasm; genital organs, prostate), Hoffbeck says.

Private insurers often have more liberal policies than Medicare regarding screening studies, although they vary greatly from payer to payer. You should check your contracts and, if in doubt, contact the appropriate medical director directly to ensure you are coding these exams correctly.

Both Medicare carriers and private payers loosen restrictions when patients have symptoms necessitating prostate exams. If the oncologist identifies an abnormality of the prostate during a routine physical that may indicate a problem, he or she orders blood tests to determine if the patient has elevated levels of PSA. Assign 84153 (Prostate specific antigen [PSA]; total) for such tests.

Among the ICD-9 codes that may be assigned are those in the 600.x series (e.g., 600.1, Hyperplasia of prostate; nodular prostate), 601.0-601.3 (Inflammatory diseases of prostate), 602.8 (Other specified disorders of prostate), or 602.9 (Unspecified disorder of prostate). Like G0103, 84153 is classified as status X by Medicare.

Normal levels of PSA are 3-4 mg/ml, according to medical bulletins. Levels above 4.0 generally indicate disease of some sort, while 10.0 mg/ml has been defined as "cancer levels." At this point, a second PSA test may be conducted to measure "free PSA," which represents PSA not chemically bound to other factors in the serum as total PSA is. CPT code 84154 (Prostate specific antigen [PSA]; free) is assigned, along with ICD-9 code 790.93 (Nonspecific findings on examination of blood; elevated prostate specific antigen).