Pathology/Lab Coding Alert

Grasp code and compliance tips.

If your lab runs plenty of prostate specific antigen (PSA) tests, you need to make sure you know the procedure and diagnosis coding rules that will get your claims paid.

That’s not all: Clean PSA claims also means not running afoul of compliance rules. Read on to glean four simple strategies for perfect PSA billing and reimbursement.

Step 1: Check the Reason for the Test

Make sure you know two procedure codes that you’ll commonly use to report a lab test that measures PSA levels in the patient’s blood. The code choice you make will depend on the reason the ordering physician requests the test.

Option 1: You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test (PSA)). Be aware that other payers may follow Medicare guidelines, so you should know your payers’ expectations.

Tip: Physicians order screening tests in the absence of signs or symptoms of disease to assess possible prostate cancer. That means you shouldn’t report G0103 for patients with a symptom or diagnosis that indicates the need for a diagnostic test.

Option 2: If the ordering physician requests a diagnostic PSA test from your clinical laboratory, you will not report G0103. Instead, choose from the following three codes based on the type of test requested:

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

The most common test to evaluate blood PSA level as an indicator of prostate cancer is total PSA (84153). The other tests evaluate PSA fractions, rather than the total level. “Code 84152 is for the complexed portion that is considered bonded to the proteins in the blood, [while] 84154 is used to determine the 10 percent that is not bound to the protein,” says Becky Boone, CPC, CUC, CPMA, a senior coder at The Coding Network, LLC in Columbia, Mo.

Clinicians may order a diagnostic total PSA test 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.

Key: Consulting the physician’s ordering diagnosis is the only way you’ll know whether to code a screening or a diagnostic PSA test.

Tip: “To be eligible for a screening PSA, the patient should have no prior history of prostatic carcinoma and no signs or symptom suggestive of that diagnosis. A screening PSA is payable once every year,” says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Diagnostic PSA tests, such as 84152, 84153, and 84154 have a wide range of acceptable diagnoses, Ferragamo adds, as long as the diagnosis indicates medical necessity.

Step 2: Match the Diagnosis to the Reason

For a screening test for a patient with no signs or symptoms of disease, you should use diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate). If you report a different diagnosis code with the G0103, Medicare will not pay for the test. You must use the screening ICD-10-CM as the first-listed diagnosis code, even if the test results in an elevated PSA finding reportable with an additional code.

Diagnostic: When the ordering physician indicates signs, symptoms, or diagnosis as the reason for the PSA test, and the lab reports a diagnostic test code such as 84153, you should use the relevant ICD-10-CM codes.

For instance: If the physician indicates benign prostatic hyperplasia (BPH) based on clinical presentation, you might report one of the following codes:

• N40.0 (Enlarged prostate without lower urinary tract symptoms)
• N40.1 (Enlarged prostate with lower urinary tract symptoms).

More choices: If the ordering physician documents a more specific diagnosis, such as prostate cancer or past PSA test results, you should report the appropriate code. For example, you might report C61 (Malignant neoplasm of prostate) or R97.21 (Rising PSA following treatment for malignant neoplasm of prostate).

If the clinician notes only signs and symptoms, you should report those condition(s) with the appropriate ICD-10-CM diagnosis, such as R39.11 (Hesitancy of micturition). Most payers consider many diagnosis codes indicating urological signs or symptoms as payable for PSA testing, such as the following:

• R31.0 (Gross hematuria)
• R31.1 (Benign essential microscopic hematuria)
• R35.0 (Frequency of micturition)
• R35.1 (Nocturia).

Test results: If your lab reports an elevated PSA level to the physician who ordered the PSA test, the clinician may then report R97.20 (Elevated prostate specific antigen [PSA]). If it is a screening test, Z12.5 should still be the first-listed code.

Step 4: Check Whether More Z Codes Apply

ICD-10-CM includes Z codes that indicate when a patient has a personal or family history of illness that may impact current healthcare decisions, even though the patient doesn’t currently have the illness. You’ll often use personal history codes with codes for follow-up after disease treatment is complete. You also might use family history codes with screening codes to explain the need for a test or procedure. Two highly common examples are Z80 (Family history of primary malignant neoplasm) and Z85 (Personal history of malignant neoplasm). Both diagnostic codes will require increased specificity.

For instance: If the lab performs a PSA test (such as 84153) more than a year after successful treatment for a prostate cancer patient, you should not use a prostate cancer diagnosis (C61). Instead, you should report Z85.46 (Personal history of malignant neoplasm of prostate). For a family history of prostatic cancer, use Z80.42 (Family history of malignant neoplasm of prostate). Mislabeling the patient as an active cancer patient could affect his ability to get health or life insurance or affect his treatment by other physicians for other conditions.

“There are a few Z codes that can be used as first-listed diagnoses,” states Dee Mandley, RHIT, CCS, CCS-P, president of D. Mandley & Associates, LLC in Stow, Ohio. You can find these at the ICD-10-CM Official Guidelines for Coding and Reporting, found at:  www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf. For instance, the guidelines state, “A screening code may be a first-listed code if the reason for the visit is specifically the screening exam.”

Step 4: Fulfill ABN Needs

Medicare pays for only one screening PSA per year. But Medicare (and other payers) may reimburse you for as many diagnostic PSA tests per year the patient needs, if you have a documented payable diagnosis demonstrating medical necessity.

Check with your payer: Each payer will have a list of acceptable covered diagnoses for PSA tests. If you bill any code within this list, you should not face denials. Make sure that you have documentation supporting the diagnosis code choice from the physician client, because labs don’t assign the ordering diagnosis.

Pitfall: Labs often don’t have access to the patient’s testing history. Educate your physician clients to check the patient’s PSA testing frequency before ordering the screening test.

ABN: If the screening test exceeds the frequency limitation, or the diagnostic test doesn’t have a payable diagnosis, your lab’s earnings could be on the line. That’s why you need to work with your physician clients to make sure they obtain a signed Advance Beneficiary Notice (ABN), if needed. That way the lab can bill the patient for the test when the payer denies the charge.