Pathology/Lab Coding Alert

Find out when to switch from screening to diagnostic PSA codes.

When you bill a prostate case to Medicare, you face some different codes and coverage rules than you’d see with a commercial payer.

Track the arc of the following prostate cancer case with lab tests and pathology services for a 62-year-old Medicare beneficiary to make sure you know the drill for accurate coding and payment.

Look For Case Details Will Drive Your Coding

Suppose you encounter this scenario:

Based on screening prostate specific antigen (PSA) level of 12.4 following a PSA of 3.8 the prior year, the physician orders a prostate biopsy with the following findings:

Pathology gross description:

• Specimen A1: Right prostate biopsy consists of tan needle biopsy core, inked and identified as apex, and submitted entirely in one cassette. Standard sectioning includes four hematoxylin and eosin (H&E) slides.
• Specimen A2: Right prostate biopsy consists of tan needle biopsy core, inked and identified as medial, and submitted entirely in one cassette, with standard sectioning.
• Specimen B1: Left prostate biopsy consists of tan needle biopsy core, inked and identified as apex, and submitted entirely in one cassette, with standard sectioning.
• Specimen B2: Left prostate biopsy consists of tan needle biopsy core, inked and identified as medial, and submitted entirely in one cassette, with standard sectioning.
• Specimen B3: Left prostate biopsy consists of tan needle biopsy core, inked and identified as base, and submitted entirely in one cassette, with standard sectioning.

Final pathologic diagnosis:

• Specimen A1: Adenocarcinoma; Gleason score: 7 (4+3); Tumor quantitation: approximately 30 percent; Perineural invasion: present
• Specimen A2: Adenocarcinoma; Gleason score: 7 (4+3); Tumor quantitation: approximately 45 percent; Perineural invasion: present
• Specimen B1: Adenocarcinoma; Gleason score: 7 (4+3); Tumor quantitation: approximately 75 percent; Perineural invasion: not identified.
• Specimen B2: Adenocarcinoma; Gleason score: 7 (4+3); Tumor quantitation: approximately 75 percent; Perineural invasion: not identified.
• Specimen B3: Adenocarcinoma; Gleason score: 7 (4+3); Tumor quantitation: approximately 50 percent; Perineural invasion: not identified.

Based on the pathology report and rising PSA above 10, the physician orders staging studies for metastasis, with negative findings. The physician proceeds with chemical hormone deprivation for two months followed by directed radiation to the prostate for seven weeks. The physician continues hormone treatment for eight months, ordering four serial PSA tests during that time until the final reading is below 1, indicating that the patient is in remission. The physician continues with semiannual PSA tests for the first year, with further follow-up test frequency based on results.

See How Dx Changes for PSA Test Orders

The many PSA tests documented in this case represent multiple claims over a long period of time, but they provide a good example of how your diagnosis coding must change to indicate medical necessity for each test. The ordering physician may assign the ICD-10-CM code, but if not, you can assign the appropriate code based on the narrative diagnosis.

Screening: For the initial PSA assays that the physician identifies as screening tests, the appropriate diagnosis code is Z12.5 (Encounter for screening for malignant neoplasm of prostate). Medicare “covers … PSA blood tests once every 12 months for men over 50 (starting the day after your 50th birthday)” (www.medicare.gov/coverage/prostate-cancer-screenings). Medicare requires you to bill the screening test procedure using G0103 (Prostate cancer screening; prostate specific antigen test (PSA))

Limit: You should use Z12.5 and G0103 only for a Medicare patient who has never received a prostate cancer diagnosis and who is not showing any signs or symptoms, such as an enlarged prostate, prior elevated PSA levels, or other symptoms or signs that may point toward prostate cancer.

During cancer treatment: For the four serial PSA tests ordered during the course of treatment, you should report the diagnosis as C61 (Malignant neoplasm of prostate). That means you also should not report the screening procedure code (G0103).

Instead, code the diagnostic PSA test as 84153 (Prostate specific antigen (PSA); Total).

Caveat: Occasionally, a physician will order a complexed or free PSA test, which you should not report using 84153, instead turning to 84152 (… complexed (direct measurement)) or 84154 (… free).

During remission: When the patient has completed the cancer treatment and the physician indicates no further signs of cancer, you’ll need a different diagnosis for follow-up PSA testing. In those cases, turn to Z85.46 (Personal history of malignant neoplasm of prostate). Don’t revert to the screening PSA procedure code (G0103), but stick with 84152 to document the PSA test.

Key: PSA serves as a marker for the progress of most prostate tumors during treatment and in detecting metastatic or persistent disease following treatment, according to the Medicare National Coverage Determinations (NCD) Manual found at >https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=152&ncdver=1.

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

Follow Medicare Rules for Prostate Biopsy

Medicare requires you to use G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method) as the one-size-fits-all code for a pathology prostate-biopsy exam.

You must report just one unit of G0416 for prostate tissue sampled on a single date of service regardless of the number of specimens, biopsy cores, or sampling method (such as prostate saturation biopsy).

Non-Medicare: For all other payers that don’t follow Medicare rules, you would report a prostate biopsy pathology exam using 88305 (Level IV - Surgical pathology, gross and microscopic examination … Prostate, needle biopsy …) for each separately identified core in a prostate biopsy case.

Fee impact: The 2022 Medicare Physician Fee Schedule (MPFS) national nonfacility amount for G0416 is $358.52, compared to $71.98 for 88305 (conversion factor 34.6062).

Unit of service: The real pay difference between using G0416 versus 88305 results from the unit of service that applies to each code. For 88305, the unit of service is one per each separately identified needle core biopsy — 5 in this case — which equates to $359.90. “This is a small case, but it would not be unusual to receive 10 or more needle core specimens in a single prostate biopsy case,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas. Ten cores reported using 88305 would equate to almost twice the pay as a single unit of G0416.

The unit of service for G0416 is one per date of service, regardless of the number of core biopsies. Medicare enforces that limit with a Medically Unlikely Edit (MUE) of one, and an MUE Adjudication Indicator (MAI) of 2, which identifies the edit as a date-of-service MUE.