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Pathology/Lab Coding Alert

Screening PSA Is Another Story:

You Dont Get Paid Under Diagnostic PSA Rules

Published on Fri Aug 01, 2003

Forget everything you just learned about diagnostic PSA coding. If you want to report a screening PSA test, you have to use different diagnosis and procedure codes.
 
PSA screening for Medicare patients has specific coverage guidelines observed by all carriers. Both procedure and diagnosis coding are different for screening PSA than for diagnostic PSA.
 
CMS defines screening as testing for disease or disease precursors so that early detection and treatment can be provided for those who test positive for the disease. Physicians order these tests for patients without signs, symptoms or even exposure to a given disease. Because physicians order a screening PSA when the patient has no prostate symptoms, you should not report any of the ICD-9 codes from the covered National Coverage Determination (NCD) list for the screen, says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa.
 
Instead, you should bill Medicare for a screening PSA using diagnosis code ICD9 V76.44 (Special screening for malignant neoplasms, prostate), according to the Medicare Carriers Manual (MCM) section 4182.7.
 
Similarly, Medicare requires a different procedure code for screening PSA than for diagnostic PSA. Report HCPCS level II code G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total) for screening rather than CPT code 84153 (Prostate specific antigen; total). According to the MCM, you must meet the following requirements to receive reimbursement for G0103:
 
 Medicare covers screening PSA tests at a frequency of once every 12 months for men who have attained age 50 at least 11 months have passed following the month of the last Medicare-covered screening PSA
  Physicians perform screening PSA tests to detect the marker for adenocarcinoma of prostate
  The beneficiarys physician, physician assistant, nurse practitioner, clinical nurse specialist or certified nurse must order the PSA screening.
 
If you know that the patient had a screening PSA more recently than 11 months ago, you should obtain a signed advance beneficiary notice (ABN) so that the patient accepts financial responsibility for the test, Wolfgang says. You should then submit the claim with modifier -GA (Waiver of liability statement on file) to indicate that you have a signed waiver.
 
Coding and billing screening PSAs for non-Medicare patients is another story. Many third-party payers dont have a screening-specific code for PSA tests, so your documentation and ICD-9 code choice must indicate that the physician did not order 84153 as a diagnostic test. Third-party payers are notorious for not covering screening PSAs, so be sure to check with the payer prior to administering the test so you can inform the patient whether he will have to pay for the screening.

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