Urology Coding Alert

Urologists now can bill Medicare for prostate cancer screening (G0103), but there is some confusion about which codes to use and when to use them. You must use the correct codes, not only for Medicare but for commercial insurance as well because they often do not accept HCPCS codes, which includes G0103.

There are also times when the urologist uses the test for reasons other than screening. Determining when you are crossing over into a diagnostic test is important for coding and reimbursement purposes.

The American Urological Association (AUA) fought hard for, and won, Medicare reimbursement for prostate cancer screening. As of 2000, Medicare pays for one PSA (prostate specific antigen) test a year if the patient shows no signs or symptoms of prostate cancer. PSA is a tumor marker for adenocarcinoma of the prostate. It is only one indicator of the patient having prostate cancer and is also a useful tool in following the progress of the cancer.

Diagnosis Coding for Medicare

Diagnosis coding can be the trickiest part of billing for a PSA screening. In terms of Medicare, you should use V76.44(special screening for malignant neoplasms; other sites; prostate), says Michael Ferragamo, MD, a urologist and coding expert who practices with Ferragamo, Bruno, Efros, PC in Garden City, N.Y. You must specify that its a screening process. Even though V-codes are notorious for being rejected, Medicare will pay for V76.44 once a year, he says.

You also can use V16.42 (family history of malignant neoplasm; genital organs; prostate) as a secondary diagnosis. You dont really have to use V16.42, since you have to use V76.44 anyway, says Ferragamo. If you are screening someone for prostate cancer, you must use V76.44 for Medicare. But using V16.42 as a secondary diagnosis to V76.44 makes your case for reimbursement stronger.

In addition, some insurance companies will allow you to use 600 (hyperplasia of prostate), not only for a PSA diagnostic test, but for a sonogram of the prostate using CPT code 76872 (echography, transrectal). But, some Medicare carriers will not. Urologists need to check with their local carrier. In any event, once you have detected an abnormality even if it is only an enlarged prostate with no nodule the PSA is no longer a screening test.

Screening means you take a man with a normal prostate, and do a test that will diagnose an inapparent cancer of the prostate, says Ferragamo. Youre doing the PSA as a screen to find an abnormality.

Coding Urinary Disorders

ICD-9 code 600 is not classified as a neoplasm. Hyperplasia of prostate is the result of an enlarged and/or inflamed prostate. Generally, it does not develop into a malignancy, although it can. The most common problem associated with hyperplasia of the prostate is urinary disorders, such as incomplete emptying, bladder infections, etc. The physician can tell via digital rectal exam (DRE) whether the patient has hyperplasia of the prostate. Testing for a possible malignancy, on the other hand, requires blood work and/or pathology.

Of course, the PSA test also can be done as a diagnostic test. Many carriers, however, will not allow you to use 600 as the diagnosis code. They dont deem hyperplasia of prostate as a medical necessity, explains Roseann Lightbody, CPC, a coder for Urology Specialists, a 12-urologist practice in Charlotte, N.C. You shouldnt use 600 for the screening anyway, not only because it doesnt prove medical necessity, but also because it is not a screening code. Again, the correct screening code is V76.44.

Whether you can use 600 as the diagnosis code for a PSA test depends on your carrier. Lightbody uses 596.0 (bladder neck obstruction). The obstruction in the descriptor is caused by the enlarged prostate, which is diagnosed by DRE. But the actual reason for the PSA test now no longer a screen because there are signs and symptoms is the obstruction. According to ICD-9, 596.0 comprises an acquired contracture or an acquired stenosis caused, in this case, by the enlarged prostate.

With BPH (benign prostate hyperplasia the term commonly used when talking about 600), most patients are referred to the urologist by an internist for further workup, says Ferragamo. So its the internist who does the DRE and PSA. And theyre the ones billing 600 and finding that carriers wont pay. The urologist then does his or her own PSA and performs further testing.

Not every urologist believes in screening, but most do, says Ferragamo. If all the patient has is BPH with no nodule or any other sign or symptom, then you cant expect payment for the (PSA) blood test. What we do is we call the payer, whether its Medicare or commercial, and ask what diagnosis codes they require for screening for cancer of the prostate. Most carriers, he says, will not allow 600. Then, we leave it up to the patient, but we ask the patient to sign a waiver. The waiver means that if the insurance company or carrier will not pay for the test, the patient is responsible for reimbursement. The urologist usually tells the patient, Id like to do the blood test since your prostate is enlarged, but the test may not be covered, says Ferragamo. Many labs charge from $55 to $75 for this test, he adds. Clearly, the patient needs to know the pros and cons, and then make the decision. As mentioned above, however, some carriers and payers do allow PSA testing based on 600, and some will reimburse you for going straight to the ultrasound.

Using Codes G0103 and 84153 Properly

If the test is done on a Medicare patient and it is a screening test, you would use G0103 (prostate cancer screening; prostate specific antigen test [PSA], total) for the procedure code. If the test is done on a Medicare patient and you suspect carcinoma because there is a clinical finding, however, you would use 84153 (prostate specific antigen [PSA]; total). With 84153, the diagnosis code is essential. It depends on the carrier, says Ferragamo. You need to check with your payers to see what they will cover. Call your local carrier to determine what diagnosis code they prefer for 84153.

In addition to the cancer diagnosis codes, covered ICD-9 codes for 84153 include urinary tract infection (599.0), various specified and unspecified prostate disorders, urinary frequency (788.41), nocturia (788.43), and slowing of urinary stream (788.62), says Ferragamo.

The correct diagnosis code is necessary whether you do the test yourself, or order it from a lab, notes Ferragamo. The lab needs the diagnosis to report with the procedure code it uses 84153.

DRE Also Paid By Medicare

When Medicare made the determination in December 1999 to pay for PSA screening, it also said it would pay for one DRE a year. There is no CPT code for this. A rectal exam is included in an office visit. There is another HCPCS code G0102 (prostate cancer screening; DRE). But you would only bill G0102 if the rectal exam was all you did during an office visit a highly unlikely occurrence.

In terms of charging separately for the G0102 from the office visit, this kind of split billing is similar to Medicares guidelines regarding charging the patient for preventive-medicine services (not covered by Medicare) and covered services provided in the same encounter. For example, a patient comes in for an annual exam and has dysuria (788.1), requiring an additional workup. Medicare requires that the allowed amount for the sick part of the well visit, in this case the DRE, be subtracted from the physicians charge for the preventive service, explains Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, compliance and reimbursement consulting company based in Denver. In that case, the fee for the preventive service is reduced. For example, the physician charges $100 for the annual physical (e.g., 99397). Medicare covers approximately $30 for a 99212 (office or other outpatient visit for the E/M of an established patient). The $30 is subtracted from the $100 with the patient owing the balance of $70. Out of courtesy and in a sense of goodwill toward the patient, I would do the same thing with the G0102, says Page. I would subtract the allowable for the DRE about $10 from the charge for the preventive service. Note that you cannot perform this calculation with an office visit. The DRE is included, but only with a preventive-medicine services visit. This is probably something that would be more likely to be done by an internist than by a urologist.

Tip: Note that 84154 (free PSA) is not covered as a screening test. When submitting claims for 84154, be prepared to document an elevated PSA and/or previous negative prostate biopsies.