Urology Coding Alert

If you scan the list above, you'll notice that "hyperplasia of prostate" code 600.0 (Hypertrophy [benign] of prostate) is not listed as a covered diagnosis for PSA for Medicare patients. "Where previously many states allowed a diagnostic PSA (CPT code 84153) for BPH, the new national guidelines for Medicare carriers, which will replace LMRPs, do not list 600.0 as a 'payable' code," Hause says.

When PSA tests are used to "screen" patients, effectively conveying medical necessity to payers can get tricky because the patients are not necessarily exhibiting identifiable symptoms of prostate cancer and also because Medicare carriers and third-party payers require the use of different CPT codes.

"Screening," as defined by CMS, "is the testing for disease or disease precursors so that early detection and treatment can be provided for those who test positive for the disease." These tests are performed for those patients without signs, symptoms, or even exposure to a given disease for precautionary purposes.

PSA screening for Medicare patients has specific coverage guidelines, observed by all Medicare carriers, for the Medicare-specific PSA screening HCPCS code G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total). According to the Medicare Coverage Issues Manual, the following requirements must be met to be reimbursed for G0103:

Although no specific diagnosis codes are mentioned in the CIM to be used with G0103, carriers typically require specific ICD-9 V codes, Hause says. "You should check with your local Medicare carrier for guidance before choosing a diagnosis code."

According to Brady, one of the more common covered screening diagnosis codes is V76.44 (Special screening for malignant neoplasms; other sites; prostate). Don't forget that you have to use fourth- and fifth-digit subclassifications when they are available, she reminds fellow coders.

"If the patient is known to have had a screening PSA more recently than 11 months, providers should ask the patient to sign an ABN accepting financial responsibility for the test," Hause says.

Coding and billing screening PSAs for non-Medicare patients is another ballgame.

Third-party payers don't have a screening-specific code for PSA tests, so it is imperative that your documentation and ICD-9 code choice indicate that 84153 is not being performed as a diagnostic test. Third-party payers are notorious for not covering screening PSAs, so be sure to check with the payer prior to administering the test so you can inform patients that they will have to pay for the screening. "If they want to pay for it themselves," Brady says, "you have to have them sign an ABN prior to administering the test." Your claim should then be submitted with the -GA modifier to indicate that a waiver has been signed.

When a patient undergoes a PSA test, most offices send the blood work to a lab for analysis. This means the results of the PSA can't be reported on the initial 84153 claim because the diagnosis is not determined during the patient's visit. If the results of the test do indicate elevated antigen levels, the patient usually returns to the urologist's office for a follow-up visit to discuss the results.

When the results of a diagnostic or screening PSA reveal elevated antigen levels, your primary diagnosis assigned to the follow-up visit should reflect the test results, Brady says. "The only time a primary diagnosis of a patient's condition is reported with signs and symptoms on a claim is when the diagnosis has been reached the day of the visit, during the patient encounter."

CMS instructs you to use diagnosis code 790.93 (Elevated prostatic specific antigen) if the PSA indicates an elevated antigen level. If a more specific diagnosis is provided, choose an ICD-9 code that more accurately reflects the test results, e.g., prostate cancer in a patient with an established diagnosis of prostate cancer, in whom elevated PSA levels are part of the disease process.