Pathology/Lab Coding Alert

Match diagnosis code to procedure code.

When your lab gets a specimen with an order for total prostate specific antigen (PSA), you’ll always perform the same test, but did you know you won’t always report the same procedure code?

If you don’t select the proper code — and provide all the supporting documentation to justify your code choice — you could be facing denials for you lab’s PSA services. Read on to get the low-down on how to document and code your PSA procedures to earn all the pay your lab deserves.

Check Reason for the Test

You have two procedure codes to choose from for a PSA test, and which you choose will depend on the reason the ordering physician requests the test.

You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test [PSA]), says Elizabeth Hollingshead, CPC, CUC, CMC, CMSCS, corporate billing/coding manager for a practice in Marysville, Ohio. Some other payers follow these same guidelines.

On the other hand, for a diagnostic PSA test, you report 84153 (Prostate specific antigen [PSA]; total), says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook.

Consulting the ordering physician’s documentation is the only way you’ll know whether to code a screening or a diagnostic PSA test. “To be eligible for a screening PSA, patients can never have had a prostate cancer diagnosis, and they have to wait 365 days between draws,” Hollingshead explains. 

If it’s a diagnostic PSA, there is a wide range of diagnoses that the ordering physician might use to show medical necessity for the test, and there is no time restriction on how often the physician can order the test. 

Match Diagnosis to Reason

For a screening test for a patient with no signs or symptoms of disease, you should use diagnosis code V76.44 (Special screening for malignant neoplasms; other sites; prostate) as the reason for the test. With ICD-10, you’ll report Z12.5 (Encounter for screening for malignant neoplasm of prostate).

If you report another diagnosis code with the G0103, Medicare will not pay for it. You must use a screening diagnosis with a screening CPT® code. “In my experience, V76.44 is the only code Medicare will allow for a screening PSA,” Hollingshead confirms. “If the physician suspects something else, you might need to look at using a diagnostic PSA.”

Official word: CMS’s Medicare Claims Processing Manual, Chapter 18 - Preventive and Screening Services, (which can be found online at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf) guides you on this requirement: “Prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using screening (‘V’) code V76.44.”

Diagnostic is different: When the physician orders a diagnostic PSA test, and the documentation specifies that the test result shows an elevated PSA, you should report 790.93 (Elevated prostate specific antigen [PSA]) as the diagnosis. When ICD-10 comes around, you’ll use R97.2 (Elevated prostate specific antigen [PSA]).

If the test results are normal, however, you should report the reason the physician ordered the test, such as benign prostatic hyperplasia (BPH), using a code such as one of the following:

• 600.00 — Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) (ICD-10: N40.0, Enlarged prostate without lower urinary tract symptoms)
• 600.01 — Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) [ICD-10: N40.1, Enlarged prostate with lower urinary tract symptoms].

Alternative: If the ordering physician documents a more specific diagnosis, such as prostate cancer, you should report the appropriate code (185, Malignant neoplasm of prostate; ICD-10: C61, Malignant neoplasm of prostate). 

Or if the physician only notes signs and symptoms without indicating BPH, you should report that condition, such as 788.64 (Urinary hesitancy; ICD-10: R39.11, Hesitancy of micturition), Ferragamo says. 

According to recent LCDs, Medicare considers many ICD-9 codes indicating urological signs or symptoms — such as 599.71 (Gross hematuria; ICD-10: R31.0, Gross hematuria), 599.72 (Microscopic hematuria, ICD-10: R31.1, Benign essential microscopic hematuria), 788.41 (Urinary frequency; ICD-10: R35.0, Frequency of micturition), or 788.43 (Nocturia; ICD-10: R35.1, Nocturia) — as payable diagnoses for PSA determinations.

Check with your payer: The covered diagnoses for a PSA test vary from payer to payer. Each payer will have a list of acceptable covered diagnoses. If you bill any code within this list, you should not face denials. Regardless of the payer’s coverage determinations, you need to be sure that you have documentation to support your diagnosis choice.

Watch Out For Annual Coding Limits

Medicare only pays for one screening PSA per year. But Medicare (and other payers) may reimburse you for as many diagnostic PSAs per year the patient needs, as long as you have a payable diagnosis.

Beware: You may not know if the patient has had a screening PSA at another lab sometime within the 365 day limit. If you suspect that might be the case, you might want to have the patient sign an advance beneficiary notice (ABN) agreeing to pay for the test himself if the payer refuses to reimburse for the earlier than usual PSA screening.