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 [...]