Pathology/Lab Coding Alert

NCD gives medical necessity with new codes

Expecting to get paid for prostate specific antigen based on urinary hesitancy or benign prostatic hypertrophy? Then you-d better update your records to include new ICD-9 codes and updated laboratory National Coverage Determination rules, both effective Oct. 1.

You-ll also need to know about new ICD-9 codes to report Pap smear and estrogen receptor test results--codes that could help show medical necessity for further procedures. CMS Adds 600.00 to Covered List After removing BPH in 2003 as a covered condition for diagnostic PSA, Medicare brings it back in the current NCD update. Change Request 5293, issued Sept. 7, adds 600.00 (Hypertrophy [benign] of prostate without urinary obstruction) to the list of covered ICD-9 codes. The change request also adds the following prostate hyperplasia ICD-9 codes, making diagnostic PSA payable for many 600 category codes:

- 600.10--Nodular prostate without urinary obstruction

- 600.11--Nodular prostate with urinary obstruction

- 600.21--Benign localized hyperplasia of prostate with urinary obstruction. Example: A physician orders a PSA test for a patient diagnosed with BPH based on symptoms of urinary retention (788.20) and frequency (788.41).

Old way: The diagnostic test code is 84153 (Prostate specific antigen (PSA); total). In the past, you would have had to report a symptom code (788.20 or 788.41), which the ordering physician might not have provided to the lab.

New way: Now you can report the physician's BPH diagnosis (600.00). This change helps labs because physicians typically order the test with a diagnosis rather than the presenting symptoms that prompted the diagnosis.

Exception: Regardless of the reason for the test, when a diagnostic PSA test reveals an elevated antigen level, the diagnosis should reflect the results. CMS instructs coders to report 790.93 (Elevated prostate specific antigen) when the test shows elevated PSA.
 
If the physician provides a more specific diagnosis, however, choose an ICD-9 code that accurately reflects the patient's condition. For example, if the physician has established a diagnosis of prostate cancer, report the appropriate code, such as 185 (Malignant neoplasm of prostate) rather than elevated PSA (790.93).

Don't miss: Screening PSA tests--ordered with no signs or symptoms--are a different matter. You should report annual PSA screenings with G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total), not 84153. Make sure tolink G0103 to V76.44 (Special screening for malignant neoplasms; other sites; prostate) as the reason for the test. New Symptom Codes Indicate PSA, Urine Culture The most recent ICD-9 update adds two new urinary symptom codes to improve coding specificity: 788.64 (Urinary hesitancy) and 788.65 (Straining on urination).

Coders will benefit from the addition of 788.64 and 788.65, two conditions that were previously not listed, says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting & Coding Education [...]