Revenue Cycle Insider

Understand medical necessity to arrive at the correct test code.

Your lab probably gets frequent requests for prostate-specific antigen (PSA) tests. But do you know how to differentiate between the different tests? more, are you correctly matching your ICD-10-CM coding with the right CPT^® or HCPCS Level II codes?

Here are three frequently asked questions about this common testing procedure. Read the answers closely, and you’ll be producing clean PSA test claims in no time.

What Is the Difference Between a Screening and a Diagnostic PSA Test?

This question is central to accurate PSA test coding. Not only does the correct answer enable you to correctly code for the test, but it will also guide you to the best possible diagnosis code to demonstrate medical necessity behind the provider’s order for the test.

Simply put, a screening test is preventive in nature. A provider should order one for a patient who has never received a prostate cancer diagnosis and who is not showing any signs or symptoms that may point toward prostate cancer, such as an enlarged prostate (which a provider may refer to as benign prostatic hyperplasia, or BPH), or elevated PSA levels.

On the other hand, a provider should order a diagnostic test on a patient who is exhibiting the signs and symptoms listed above, who is under a provider’s care after prostate cancer has been diagnosed, or who has a personal history of prostate cancer.

How Are Screening and Diagnostic PSA Tests Coded?

For screening PSA tests, you should report either HCPCS Level II code G0102 (Prostate cancer screening; digital rectal examination) or G0103 (… prostate specific antigen test (PSA)) depending on the testing methodology.

Diagnostic PSA tests are a little more complex to code, however. The test you’ll see most often is 84153 (Prostate specific antigen (PSA); total), which is used to measure the total PSA results. Less commonly used tests are 84152 (… complexed (direct measurement)), which directly measures the fraction of the antigen bonded to proteins in the blood, and 84154 (... free), which measures the approximately 10 percent of the antigen that is not bonded.

Remember: If your lab tests for both total and free PSA, then calculates the complexed fraction, you should not separately report 84152 for the calculated value.

What Diagnosis Codes Justify Medical Necessity for the Tests?

If the provider indicates they are ordering the test as a screening and doesn’t document any signs, symptoms, or conditions, you’ll link ICD-10-CM code Z12.5 (Encounter for screening for malignant neoplasm of prostate) to G0102 or G0103.

But “when the test is performed for diagnostic purposes, valid diagnoses for coverage may range from a known condition to determine the status of the disease or for various signs and symptoms,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC in Centennial, Colorado.

Among those diagnoses that justify medical necessity for 84152-84154 are signs and symptoms codes such as:

• R31.0 (Gross hematuria)
• R31.1 (Benign essential microscopic hematuria)
• R35.0 (Frequency of micturition)
• R35.1 (Nocturia)
• R39.11 (Hesitancy of micturition)
• R97.20 (Elevated prostate specific antigen (PSA))
• R97.21 (Rising PSA following treatment for malignant neoplasm of prostate)

When the provider uses these codes, you can show that the PSA test is being used to “assist in the decision-making process for diagnosing prostate cancer,” according to the Medicare National Coverage Determination (NCD) >Prostate Specific Antigen.

“PSA also serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment,” the NCD continues.

This means other acceptable codes for accompanying 84152-84154 would be codes such as:

• C61 (Malignant neoplasm of prostate)
• D07.5 (Carcinoma in situ of prostate)
• D40.0 (Neoplasm of uncertain behavior of prostate)

If a provider orders a diagnostic PSA test for a patient who has successfully undergone treatment for prostate cancer, and whose cancer is now in remission, you should not use the C61 diagnosis. Instead, you should report Z85.46 (Personal history of malignant neoplasm of prostate).

How Often Can a Patient Be Tested?

Medicare covers PSA testing once every year for men over 50. That means you need to ensure the patient hasn’t had a PSA test within the past 12 months if you expect payment for a test ordered with Z12.5 as the only diagnosis.

But if your lab performs a diagnostic PSA test, you don’t have to consider the testing frequency when you file a claim.

For Medicare patients, if you’re not sure when the patient last had a screening PSA test, you should get a signed Advance Beneficiary Notice of Noncoverage (ABN) so that you can bill the patient for the test if Medicare rejects the claim.

Coding tip: Because medical necessity for a PSA test varies from payer to payer, you should always check the patient’s payer’s covered diagnosis list, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC