Pathology/Lab Coding Alert

Question: How should we report a prostate specific antigen (PSA) test for a 57-year-old man with benign prostatic hypertrophy? Should age or diagnosis rule in determining if this is a diagnostic or screening test?

Florida Subscriber

Answer: The ordering physician indicates if this is a diagnostic or screening test based on the ordering diagnosis. Alab requisition form designed to solicit this information will help clarify coding. Especially when billing Medicare for PSA, diagnostic versus screening is a critical distinction because you report the service using different procedure codes.

Generally, you perform screening tests in the absence of signs and symptoms of disease, and diagnostic tests for symptomatic patients. The patient in your example has a diagnosis of benign prostatic hypertrophy (600.0), indicating a diagnostic PSA test.

Report diagnostic tests with one of three codes, depending on the specific lab test performed: free PSA (84154, Prostate specific antigen [PSA]; free), total PSA (84153, Prostate specific antigen [PSA]; total) or complexed PSA(84152, Prostate specific antigen [PSA]; complexed [direct measurement]).

PSA is a prostate cancer marker that is found in the blood in two forms: "complexed," (bound) to a protein, or "free." Physicians may order any one of these tests for different diagnostic purposes, and you should code them accordingly.

If the ordering physician requests a screening PSA for an asymptomatic patient, Medicare requires a different procedure code. Report the service with G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total). Medicare covers screening PSAtests once a year for men at least 50 years old, subject to certain limitations. The physician must request the screening with diagnosis code V76.44 (Special screening for malignant neoplasms, prostate).