Pathology/Lab Coding Alert

Medicare began coverage for two procedures for prostate cancer screening on Jan. 1, 2000, in response to a mandate in the Balanced Budget Act of 1997. The procedures are a digital rectal exam and a laboratory blood test for PSA (prostate specific antigen). Obtaining reimbursement for these procedures requires an understanding of the difference between the level-two HCPCS and CPT codes for the tests, as well as understanding conditions of coverage.

New HCPCS Codes

The two new procedure/professional service HCPCS codes that are used to report screening for the early detection of prostate cancer are G0102 (prostate cancer screening; digital rectal examination) and G0103 (prostate cancer screening; prostate specific antigen test [PSA], total). Code G0103 is a lab test that identifies the level of an immunocytochemical marker for prostate cancer in the patients blood. G0102 involves a physical examination of the patients prostate for nodules or other abnormalities.

Subject to the restrictions laid out by the Health Care Financing Administration (HCFA), the advent of these codes means that Medicare patients who do not have symptoms or a diagnosis that supports prostate cancer tests can benefit from their use as an early-detection tool, according to Ken Wolfgang MT (ASCP), CPC, CPC-H. Wolfgang is president of Kenneth E. Wolfgang Inc. Health Services Consulting in Portland, Ore., a coding consultation company specializing in pathology. Healthcare providers should check with their other payers to determine their specific coverage policies for prostate cancer screening, he says. An appropriate ICD-9 code to identify the reason for the screening procedures would be V76.44 (special screening for malignant neoplasms, prostate).

Whether the patient comes in for a preventive medicine evaluation or presents with symptomatic complaints unrelated to prostate disease, code G0103 can be reported on the same day for the same patient as the appropriate evaluation and management (E/M) code, says Wolfgang. This code represents a screening laboratory procedure that is ordered by the patients physician or other approved healthcare provider.

On the other hand, code G0102 cannot be reported on the same day as an office visit in many cases. Doug Knapman, MBA, business manager of Professional Billing Systems Inc. of Michigan City, Ind., specializing in pathology and laboratory billing, points out that HCFA program memorandum B993760 states, A digital rectal exam that is provided on the same day as a covered E/M service is bundled into the payment for the E/M service.

Code G0102 represents an examination that should be included in the appropriate level problem-oriented E/M service. One of the three key components used to determine the service level of a problem-oriented [...]