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Answer: Diagnostic and screening prostate specific antigen (PSA) tests have different criteria and codes for Medicare. The diagnostic test(s) is covered when the patient presents with symptoms, such as incomplete bladder emptying (788.21 ), or for monitoring disease or treatment progression for conditions such as benign prostatic hypertrophy (600.0) or prostate cancer (185). The diagnostic tests are reported with one of three codes, depending on the PSA fraction measured: one for free PSA (84154, prostate specific antigen [PSA]; free), one for total PSA (84153, prostate specific antigen [PSA]; total) and one for 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." Any of these tests may be ordered for different diagnostic purposes and should be coded accordingly.
Medicare has covered screening PSA tests since Jan. 1, 2000, for the early detection of prostate cancer. These are covered in the absence of signs or symptoms of disease subject to certain limitations. When ordered by an appropriate healthcare provider, a screening PSA test is covered once every 12 months for men at least 50 years of age. The screening test is reported as G0103 (prostate cancer screening; prostate specific antigen test [PSA], total), and the appropriate diagnosis code for coverage is V76.44 (special screening for malignant neoplasms, prostate). |
