Primary Care Coding Alert

Thanks to changes in Medicare policy as of Jan. 1, 2000, family physicians now have the opportunity to encourage male patients to undergo prostate cancer screening exams. In the past, Medicare did not reimburse for either digital rectal exams (DREs) or prostate specific antigen (PSA) screening studies, although both are commonly viewed as tools that may be valuable in diagnosing cancer early. The policy changes, however, allow coverage for both tests in men 50 years of age and older.

Publicity surrounding these changes and the value of the exams enjoyed a resurgence in late April when New York Mayor and possible Senate candidate Rudolph Giuliani, 55, announced that he had been diagnosed with prostate cancer. Giulianis disease was diagnosed following a biopsy of the prostate. His physicians ordered the biopsy when a blood test showed elevated levels of prostate specific antigen, a protein commonly called PSA that is considered a marker for prostate cancer.

Although he may not have been a Medicare patient, Giulianis case underscores the significance of the January 2000 modifications to Medicare policy. The new HCPCS code for screening DRE is G0102, and the screening PSA code is G0103. Both changes were mandated in the Balanced Budget Act of 1997.

In the past, there was no code assigned to DREs, and PSAs were covered only as diagnostic studies when a patient displayed signs or symptoms clearly indicating the medical necessity of the tests.

Annual Screening Exams

Greatest risk for prostate cancer is seen in men 50 years of age or older, which is why the new screening policies were established for this age group. Physicians generally begin paying close attention to the prostate gland when a man turns 40. In general, it is typical to begin PSA screening for prostate cancer at 50, notes Anne Batson, RN, CSFNP, who works with the Northcare at the Silos family practice in Alpharetta, Ga. However, at 40 we do begin conducting digital rectal exams during routine physicals.

Charges for screening DREs in men younger than 50 are considered to be included in the preventive service code assigned most often 99386 for a new patient, age 40-64, or 99396 for an established patient age 40-64. Routine PSAs for men 40-49 are not reimbursed, and patients who request the blood test may pay up to $40 out of pocket for the exam, Batson says.

According to Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., which supports urology and family practice physicians in Broomfield, Colo., the new Medicare policy allows clinicians to order screening DREs and PSAs once a year when their patients reach 50, and receive payment when assigning codes G0102 and G0103.

Coders should note that you use the G codes only for the screening exams, Page explains. These are not the codes you would assign if a diagnosis of prostate cancer has been established.

HCPCS code G0102 has been assigned the same value as CPT code 99211, the lowest level of evaluation and management (E/M) service. Medicare policy states that a DRE performed on the same day as a covered E/M service is bundled into the payment for the E/M care. Professional coders should note, however, that if the DRE is the only service provided or is provided as part of an otherwise non-covered service (like code 99397 for a preventive visit), then G0102 will be separately payable. In this situation, Medicare will pay 80 percent of the allowable and the fee for the preventive service, so that the physician receives in total no more than the fee for the preventive service.

Code G0103 is priced at about the same payment level as 84153 (prostate specific antigen [PSA]; total), which is the code used for a diagnostic PSA test.

Page notes that coders expect the Medicare screening policy to be rigidly adhered to. Although there are physicians who believe it is important to screen high-risk patients younger than 50, she says, we are seeing no indication that Medicare will reimburse a screening exam sooner than that.

Batson agrees that clinicians sometimes encounter patients who are well served by earlier screening exams because of their risk factors. We will begin PSA screening at age 40 in men who have a strong family history of prostate cancer for instance, a brother or father who has developed the disease, she says. In addition, studies have shown that African-American men are at greater risk and tend to develop a form of very aggressive prostate cancer. Because of this, we may begin screening these individuals at 40 or 45.

Private payers may have more liberal policies than Medicare, Page notes, and advises coders to check with appropriate medical directors to determine the payers policies regarding reimbursement of these screening tests.

Diagnostic Prostate Exams

According to Batson, coding for clinically indicated PSAs was not affected by the addition of the prostate screening codes.

If, for instance, we identify an abnormality of the prostate during a routine physical that may indicate a problem, we will order blood tests to determine if the patient has elevated levels of PSA, she says. The CPT code assigned would be 84153. Among the ICD-9 codes that may be assigned in instances like this are 600 (hyperplasia of prostate), 601.0-601.3 (inflammatory diseases of prostate), 602.8 (other specified disorders of prostate) or 602.9 (unspecified disorder of prostate).

Normal levels of PSA are 3 to 4 mg/ml, Page says. Levels above 4 generally indicate disease of some sort (including cancer), while 10 mg/ml have been defined as cancer levels. At this point, she notes, a second PSA test may be conducted to measure free PSA (which represents PSA not chemically bound to other factors in the serum as total PSA is). Code 84154 (prostate specific antigen [PSA]; free) would be assigned, along with ICD-9 code 790.93 (elevated prostate specific antigen).

Family physicians most often refer patients with high PSA levels to other specialists such as urologists, who would continue diagnostic testing to determine the disease or disorder affecting the prostate. These tests may include repeated PSAs, ultrasound imaging and biopsies.

Cautious Implementation of PSA Reimbursement Policy Although prostate specific antigen (PSA) screening has been available and widely used for several years, the value of the exam has been hotly debated. Researchers and clinicians have disputed the accuracy of the exam, for instance, which some say carries a 60 percent error rate. Others have argued that, since prostate cancer is a slow-growing disease and affects mostly elderly men, early detection through PSA screening has little impact on treatment decisions. Most experts agree that these issues contributed to the cautious approach the Health Care Financing Administration (HCFA) and Medicare have taken to providing reimbursement for screening PSAs. There are many variables that have been discussed, admits Casandra Mehlan, FNP, who works with the practice of Nabors, Hader and Sanders, MD, in Atlanta. In the past, treatment decisions depended largely on the age and the health status of the patient. Historically, we saw prostate cancer mostly in men who were in their 80s or 90s and since it is such a slow-growing disease, there may have been no reason to treat it. The projected course of the disease may have been much longer than the individuals anticipated life span at that point in time. It also was discovered that these arguments created a catch-22. The reason that prostate cancer appeared most frequently in 80- and 90-year-olds was because screening was seldom done at an earlier age. Younger men in their 50s and 60s did indeed have prostate cancer, Mehlan says, but we didnt discover it until they were older and the disease was advanced. We believe that, even though it is not a perfect tool, PSA screening does help us identify prostate cancer earlier and we are able to treat it either curing it altogether or extending the patients life significantly. This discovery along with the aging of the U.S. population and a larger portion of the male population reaching the age of 50 and older increased awareness within the medical community that screening digital rectal exams (DREs) and PSAs may be valuable in diagnosing and treating prostate cancer. The change in Medicares reimbursement policy supports this and, it is hoped, will provide an incentive for more men to be screening. Family physicians already have begun to see male patients making appointments specifically for prostate cancer screening. There is a significant number of men who typically would not access the healthcare system, now making appointments because these screening exams are covered, one Midwestern physician commented.