Pathology/Lab Coding Alert

Even if your lab performs lots of prostate specific antigen (PSA) tests, you might not be getting all the pay you deserve if you don't follow these expert tips.

PSA diagnosis and procedure coding depends on one piece of information -- the reason for the test. The "reason" comes in the form of an ordering diagnosis (ICD-9 code), which you must have to show medical necessity for the test.

Unfortunately, labs don't get to pick that code, according to Stan Werner, MT (ASCP), administrative director of Peterson Laboratory Services PA in Manhattan, Kan But you can provide physician education and design requisition forms to help ensure that the physician assigns a payable diagnosis for PSA.

Do this: Make your requisition form with blanks for the physician to select either "screening" or "diagnostic" PSA. Then have the physician choose or fill in an ICD-9 code under the appropriate screening or diagnostic heading.

Physicians order screening PSA tests as a tool to identify early cases of prostate cancer. When a physician orders a PSA test for a patient who shows no signs or symptoms of disease, that's a screening test.

You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test [PSA]). Some non-Medicare payers also expect the G code for screening, but others want a CPT code, even for screening tests.

Check eligibility: For Medicare beneficiaries, prostate cancer screening using a PSA test begins for men the day after the 50th birthday. Many payers follow the same age guidelines, but check with other insurers for differences.

For Medicare beneficiaries and some other payers, you'll only use the PSA CPT code when the physician orders a diagnostic test. That's when there is an established disease/illness process or symptoms that the physician indicates as the reason for the test.

The correct code for a diagnostic PSA test for a Medicare beneficiary is 84153 (Prostate specific antigen [PSA]; total).

For instance: You should bill 84153 for observation of a rising PSA, or for a confirmed prostate cancer diagnosis that requires PSA monitoring during treatment to assure its effectiveness.

When the physician orders a screening PSA test (G0103) for a patient with no signs or symptoms of disease, you should use the following screening V code as the reason for the test:

• V76.44 -- Special screening for malignant neoplasms; other sites; prostate.

You can read the CMS guidelines for reporting this diagnosis code in The Guide to Medicare Preventive  Services manual at www.cms.hhs.gov/mlnproducts/downloads/psguid.pdf.

Know diagnostic ICD-9s: CMS has a laboratory national coverage determination (NCD) for diagnostic PSA testing that you report with 84153. The NCD provides a list of "covered diagnoses," which includes more than 35 ICD-9 codes that show medical necessity for diagnostic PSAs for Medicare patients. You can access the list at www.cms.hhs.gov/CoverageGenInfo/downloads/manual200907.pdf#20.

See "Precise ICD-9 Pick Shows PSA Medical Necessity" on page 77 to read more tips for diagnostic PSA medical necessity coding.

"Medicare only pays for one screening PSA per year," says Gaye Pratt, coder/biller for Dr. Vincent P. Miraglia in Stuart, Fla.

That's why you have to be careful about timing. Screening PSA is covered only once every 12 months for Medicare, with most commercial payers following suit.

You need to make sure that you have at least 366 days (367 for leap years) between screening PSAs. But Medicare (and other payers) might pay for more frequent diagnostic PSAs, as long as you can show medical necessity, Pratt says.

Get this limitation: According to CMS's NCD for diagnostic PSA testing, "Generally, for patients with lower urinary tract signs or symptoms, the test is performed only once per year unless there is a change in the patient's medical condition."