Pathology/Lab Coding Alert

Medicare has demoted benign prostatic hypertrophy (BPH). Although it was once considered an indication for a diagnostic prostate specific antigen (PSA), CMS did not include prostate hyperplasia on its latest list of covered diagnosis codes for the test.
 
The list is nationwide no matter what your local carrier allowed before, the National Coverage Determination (NCD) for PSA makes the rules now. You can view the directive on the Internet at http://www.cms.gov/mcd/viewncd.asp?ncd_id=40-20&ncd_version=1&show=all.

Cancer or Signs Indicate Diagnostic PSA

Symptoms indicate the need for diagnostic testing, otherwise the test is for screening purposes, 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. (See Screening PSA Is Another Story .) Because Medicare no longer considers BPH a symptom, youll have to report other symptoms to justify the diagnostic prostate lab test (84153, Prostate specific antigen; total).
 
Physicians use PSA tests to detect residual cancer post-prostate cancer removal, such as following radical prostatectomy. The test can act as a marker in following the progress of most prostate tumors once a diagnosis has been established, according to CMS, but it can also aid in the initial diagnosis of prostate cancer. PSA testing can even take diagnosing prostate cancer one step further and differentiate between benign and malignant tumors in men with signs of a potential prostate disorder, such as hematuria and other urinary tract symptoms.
 
If you scan the list in NCD Lists Covered Diagnosis Codes, youll notice that 600.0 (Hypertrophy [benign] of prostate) is not listed as a covered diagnosis for PSA for Medicare patients. While previously many states allowed a diagnostic PSA (84153) for BPH, the new national guidelines for Medicare carriers, which replace local medical review policies (LMRPs), do not list 600.0 as a payable code, Wolfgang says.

Code for BPH Symptoms, Not BPH

So whats a coder to do? If you cant list the diagnosis as BPH, list the symptoms that caused the physician to suspect BPH in the first place.
 
Its hard to imagine that there are too many men with BPH who do not have some degree of urinary retention (788.20), frequency (788.41), nocturia (788.43) or reduced urine stream (788.62), all of which are covered diagnoses for diagnostic PSA, says Robert Murray, PhD, director of technology at Midwest Diagnostic Pathology in Park Ridge, Ill., and member of the NCD negotiated rulemaking committee. 
 
You cant use symptom codes if the ordering physician doesnt note them. The solution is physician education, Murray says. Inform clients that Medicare no longer accepts BPH (600.0) for diagnostic PSA and provide the list of covered diagnoses for their referral.
 
For example, if the medical record indicates urinary retention or nocturia secondary to a suspected prostate disorder, report diagnosis codes reflecting these symptoms using 788.20 and 788.43 rather than reporting BPH (600.0).
 
Remember to code the condition to the highest degree of certainty, which may include reporting signs, symptoms, abnormal test results, or other reasons for the encounter, according to the NCD.

Report Test Results for Elevated PSA

When a diagnostic PSA test reveals an elevated antigen level, the diagnosis should reflect the results. CMS instructs coders to report 790.93 (Elevated prostate specific antigen) when the test shows elevated PSA.
 
If the physician provides a more specific diagnosis, however, choose an ICD-9 code that accurately reflects the patients condition. For example, if the physician has established a diagnosis of prostate cancer, report the appropriate code, such as 185 (Malignant neoplasm of prostate) rather than elevated PSA (790.93), which is a part of the prostate cancer disease process.