Pathology/Lab Coding Alert

From urinary symptoms to cancer, physicians may order diagnostic PSA tests for lots of reasons. Make sure you understand how ICD-9 codes can help you show medical necessity when your lab bills 84153 (Prostate specific antigen [PSA]; total).

Watch for documentation: Regardless of Medicare's "payable diagnoses" listed in the PSA national coverage determination (NCD) or other payer's coverage rules, you need to be sure that you have documentation to support your diagnosis code choice, says Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio. Distinguish Symptoms and Conditions Although physicians may order a diagnostic PSA with symptom codes such as 788.64 (Urinary hesitancy) or 788.65 (Straining on urination), you're more likely to get an order based on a diagnosis of benign prostatic hypertrophy (BPH), even if the patient presents with other symptoms.

Because you must report the BPH codes to the fifth digit, you'll have to know whether the patient has a urinary obstruction that is symptomatic so you can select the proper code as follows:

• 600.00 -- Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS)

• 600.01 -- Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS).

Exception: 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 [PSA]) when the test shows elevated PSA.

Opportunity: Following a screening PSA test that results in an elevated antigen level, the physician may order a follow-up PSA test. If you bill the second test with 790.93, you don't have to meet the screening frequency guideline of once a year. That means your lab could earn an extra $27 -- Medicare's national limitation amount for 84153 on the clinical laboratory fee schedule.

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).

If the lab performs a PSA test (84153) following successful treatment for prostate cancer, you should not use the prostate cancer diagnosis code (185). Instead, report V10.46 (Personal history of malignant neoplasm; prostate).

Mislabeling a 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.