Pathology/Lab Coding Alert

Question: Our lab received an order for a PSA test for a 55-year-old patient diagnosed with BPH who complained of reduced urination. Should we use the HCPCS Level II code or the CPT code for the PSA test?


Utah Subscriber

Answer: Because a patient complaint prompted the test, you should report the PSA test with a CPT code. On your claim, you should report the procedure as 84153 (Prostate specific antigen [PSA]; total). To show medical necessity for the test, you should use the ICD-9 code that accurately reports the patient's symptom: 788.62 (Slowing of urinary stream).

Although the ordering physician states that the patient has benign prostatic hypertrophy (BPH), Medicare and other payers do not consider prostate hyperplasia to show medical necessity for the PSA test. You should code the reported symptom of BPH (urinary stream reduction), not the BPH itself (600.0--Hypertrophy [benign] of prostate) to justify the PSA lab test.

Reserve the HCPCS Level II PSA test code (G0103--Prostate cancer screening; prostate specific antigen test [PSA], total) for tests ordered in the absence of signs or symptoms of disease. The G code describes a screening PSA for an asymptomatic Medicare patient.

Medicare covers one PSA screening per year for every asymptomatic male patient 50 years of age and older. When using G0103, you should connect it to diagnosis V76.44 (Special screening for malignant neoplasms; other sites; prostate) to ensure the claim's success.