Oncology & Hematology Coding Alert

Question: In an elderly patient, who showed signs of bone metastasis, our physician wants to avoid a prostate biopsy. The patient has very high PSA 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 and that decision follows the clinical rationale or standard of medical practice of carcinoma of the prostate C61 (Malignant neoplasm of prostate), may be used for the Lupron with a diagnosis of prostate cancer.