Primary Care Coding Alert

Question: Why doesn't Medicare cover a prostate specific antigen (PSA) test for my patients with benign prostatic hypertrophy (BPH)?


Kansas Subscriber


Answer: Medicare does not include BPH (600.00, Hypertrophy [benign] of prostate without urinary obstruction) on its list of ICD-9-CM codes covered for a diagnostic PSA (84153, Prostate specific antigen [PSA]; total).

-If the patient has symptoms of prostate carcinoma along with the BPH, such as hematuria, nocturia, urinary frequency, and slow stream, a diagnostic PSA can be covered,- states CMS in Transmittal 234.

Be careful that you-re not coding a diagnostic PSA when you should actually be reporting a screening PSA. Medicare covers an annual screening PSA testing for men over 50.

Key: Report annual PSA screenings with G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total), not 84153. Make sure to link G0103 to V76.44 (Special screening for malignant neoplasms; other sites; prostate), regardless of whether the patient has BPH.

Stay tuned: CMS is considering adding 600.00 to its list of covered diagnoses for a PSA test. Act now and get your opinion to count by logging on to www.cms.hhs.gov/coverage.

Answers to You Be the Coder and Reader Questions reviewed/provided by Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.; and Peter D. Rappo, MD, assistant clinical professor at Harvard University School of Medicine in Brockton, Mass.