Pathology/Lab Coding Alert

Educate clients -- their diagnosis coding can make or break your claim.

When your lab gets an order for a prostate specific antigen (PSA) test, you can't just assign one code based on the lab method. First, you need to determine the reason the physician ordered the test, and consider the lab method and the payer you're reporting to.

Make sure you're choosing the proper codes and assigning the proper diagnoses by learning these three expert guidelines for your PSA claims.

1. Base Coding on Screening vs. Diagnostic

When your lab performs a PSA assay, your code choice will depend on why the physician ordered the test. Medicare, and some other payers, require that you code screening PSA tests one way and diagnostic tests another.

Screening: For a screening PSA for a Medicare beneficiary you'll report G0103 (Prostate cancer screening; prostate specific antigen test [PSA]), says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. Some other payers follow these same guidelines.

Diagnostic: In contrast, if the PSA test is for diagnostic purposes you'll have three codes to choose from:

• 84152 -- Prostate specific antigen (PSA); complexed (direct measurement)
• 84153 -- ... total
• 84154 -- ... free.

Medicare indicates that 84153 is appropriate to differentiate benign and malignant disease in men with symptoms such as urinary frequency/urgency or palpably abnormal prostate gland, as well as to monitor the progress of prostate cancer following diagnosis and treatment.

Beware 'complexed' billing: Some physicians prefer to evaluate the PSA fraction that is bound to a blood protein (complexed, or cPSA) because the analysis may provide greater specificity. Studies show that cPSA may result in fewer false positives -- thus potentially lowering the percentage of healthy patients who undergo a confirmatory prostate biopsy.

Labs can either directly measure cPSA (84152) or measure total and free PSA (84153 and 84154) to calculate the free/total ratio, which approximates cPSA. Check with payers regarding coverage for these tests.

2. Let the Diagnosis Prove Your Procedure Coding

You will be able to quickly identify whether to use G0103 or 84153 by reviewing the ordering physician's documentation. Report G0103 when the physician orders a PSA test is for a patient without signs or symptoms. If the physician orders total PSA for a patient because he suspects carcinoma, for example, due to clinical findings, you would use 84153.

For screening PSA tests, report V76.44 (Special screening for malignant neoplasms; prostate) as the ordering diagnosis.

Key: Even if the PSA screening for an asymptomatic patient results in a positive finding, still report the screening HCPCS (G0103) and ICD-9 code (V76.44), instructs Jennifer Swindle, RHIT, CCS-P, CPC, CPMA, director of coding and compliance at Pivot Health LLC in Nashville, Tenn.

There are several ICD-9 codes that the ordering physician might use for a diagnostic PSA test (84153), Hines says -- such as malignant neoplasm of prostate (185), gross hematuria (599.71), or elevated PSA (790.93).

The physician may also use the patient's presenting symptoms, such as incomplete bladder emptying (788.21), grossly bloody urine (599.71) or urinary frequency (788.41) as the reason for a diagnostic PSA test. You'll find a complete list of payable diagnoses for Medicare beneficiaries by accessing the laboratory national coverage determination (NCD) at www.cms.gov/CoverageGenInfo/downloads/manual201104.pdf#20.

Beware: Because the ordering physician -- not the lab -- provides the ordering diagnosis, you need acquire a signed advance beneficiary notification (ABN) if you don't have a payable diagnosis.

3. Watch For Frequency Limits

Medicare covers screening PSA tests once every 12 months for men age 50 years and older, Hines warns. So be sure at least 11 months have passed since the patient last had a PSA screening.

Potential snag: Labs often don't have access to the patient's testing history. Educate your physician clients to check the patient's PSA testing frequency and obtain a signed ABN, if needed. That way the lab can bill the patient for the test when the payer denies the charge.