Primary Care Coding Alert

Question: I know CMS has released bulletins saying G0102 (Prostate cancer screening; digital rectal examination) is covered, but when we bill it with an E/M service and modifier -25, we are denied and told it's bundled with the E/M visit. Medicare says it will reimburse G0102 if it is the only reason a patient presents, but I can't imagine a patient coming in just for a digital rectal exam (DRE). How can I get paid?

California Subscriber

Answer: Unfortunately, you will not be able to get paid separately for G0102. Sections of the Social Security Act, as added by the Balanced Budget Act of 1997, provide coverage for certain prostate cancer screening tests and procedures subject to certain coverage, frequency and payment limitations. As of 2000, Medicare covers prostate screening tests and procedures for the early detection of prostate cancer. The screening procedures covered are the DRE (G0102) and the prostate specific antigen (PSA) blood test (G0103).

To bill G0102, you must perform the DRE on a male Medicare beneficiary over age 50 and only once every 12 months. Once a beneficiary has received any or all of the covered screening procedures, he may receive another after 11 full months has passed.

Per Medicare guidelines, billing and payment for G0102 is to be bundled into the payment for a covered E/M service (99201-99499) when the two services are furnished to a patient on the same day. If the G0102 is the only service or is done as part of a noncovered service (such as a preventive exam), G0102 is payable separately if all coverage requirements are met. In other words, if the patient is in the office for a preventive medicine visit and receives a DRE, you bill the G0102 to Medicare as long as it has been 11 full months since the last test was performed.

You should use diagnosis code V76.44 (Special screening for malignant neoplasms, prostate) in this case. If the patient is being seen for a problem, the service is "bundled" into the E/M code, and adding modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) will not eliminate the denial.

Answered by Judy Richardson, RN, MSA, CCS-P, senior consultant at Hill & Associates, a coding and compliance consulting firm based in Wilmington, N.C.