Urology Coding Alert

Juggling codes for PSA is easy

Knowing how to code for diagnosis and treatment of prostate cancer is a critical skill because more than 1.5 million American men have prostate cancer, according to the National Cancer Institute (NCI).

Typically, urologists use prostate specific antigen tests - 84152 (Prostate specific antigen [PSA]; complexed [direct measurement]), CPT 84153 (... total) and 84154 (... free) - to diagnose prostate cancer.

BPH is often the main diagnosis urologists use when performing screening PSA tests. Many urologists order PSA testing for the diagnoses in the 600 series, such as 600.x (Hyperplasia of prostate), 601.x (Inflammatory diseases of prostate) and 602.x (Other disorders of prostate). But when a urologist uses one of the 600 series of prostate hyperplasia diagnosis codes, the payer may deny the claim.

"BPH, usually, is not covered," says Jodi Stamper, CPC, of Northwest Arkansas Urology Associates. "Most of the time we deal with patients who have prostate cancer or elevated PSAs, and that's usually covered."

Link These Diagnoses to Medicare Claims for 84153

In the latter part of 2002, Medicare established a National Coverage Determination policy for ICD-9 diagnoses that would allow payment for diagnostic PSA. The following are approved diagnoses for a "diagnostic" PSA determination (84153). Note: BPH, 600.00, 600.01, etc., are not payable diagnoses.
 

185 - Malignant neoplasm of prostate
 

188.5 - Malignant neoplasm of bladder neck
 

196.5 - Secondary malignant neoplasm; lymph nodes of inguinal region and lower limb
 

196.6 - Secondary malignant neoplasm; intrapelvic lymph nodes
 

196.8 - Secondary malignant neoplasm; lymph nodes of multiple sites
 

198.5 - Secondary malignant neoplasm; bone and bone marrow
 

198.82 - Secondary malignant neoplasm; genital organs
 

233.4 - Carcinoma in situ; prostate
 

236.5 - Neoplasm of uncertain behavior of prostate
 

239.5 - Neoplasms of unspecified nature; other genitourinary organs
 

596.0 - Bladder neck contracture
 

599.6 - Urinary obstruction, unspecified
 

599.7 - Hematuria
 

601.9 - Unspecified prostatitis
 

602.9 - Unspecified disorder of prostate
 

788.20 - Retention of urine
 

788.21 - Incomplete bladder emptying
 

788.30 - Urinary incontinence, unspecified
 

788.41 - Urinary frequency
 

788.43 - Nocturia
 

788.62 - Slowing of urinary stream
 

790.93 - Elevated prostate specific antigen
 

793.6-793.7 - Nonspecific abnormal finding on radiological examination
 

V10.46 - Personal history of malignant neoplasm; prostate.

Use Code V76.44 for Routine Screening

For routine screening for prostate cancer - a test done in the absence of any signs or symptoms - use G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total) for Medicare patients and 84153 for commercial patients.

Use diagnosis code V76.44 (Special screening for malignant neoplasms; prostate) for both.

Remember that individual carriers have their own local medical review policies (LMRP) indicating which
diagnosis codes justify screening and medical necessity for 84154 and 84153.

Some carriers have LMRPs only for 84153, for example, which is covered by more diagnosis codes than 84154. Policies that refer to both PSA testing codes, however, do not distinguish between diagnosis codes by CPT code, but have overall medical-necessity lists for both 84153 and 84154. And other carriers do not reimburse total and free PSA tests on the same day.

Choose From Several Procedure Codes for Treatment

When a patient has prostate cancer, several procedures and services are applicable for treatment. Radical prostatectomies are generally performed using one of two approaches: a perineal approach, base code 55810 (Prostatectomy, perineal radical), or a retropubic approach, base code 55840 (Prostatectomy, retropubic radical, with or without nerve sparing).

Other codes in the 55810 series indicate whether or not the procedure included other structures, such as 55812 (Prostatectomy, perineal radical; with lymph node biopsy[s] [limited pelvic lymphadenectomy]), 55815 (Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes), 55842 (Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy[s] [limited pelvic lymphadenectomy]) and 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes).

For example, tests on a 58-year-old patient reveal elevated PSA levels. After checking nearby lymph nodes to see if the cancer has spread to other systems, a urologist in your practice decides to perform a radical prostatectomy. Determine which approach was used - perineal or retropubic - then code depending on which other structures were involved. In this case, the urologist used the perineal approach, base code 55810. In the process, the surgeon also removes area lymph nodes for biopsy, so the code would be 55815.

For laparoscopic radical prostatectomies, use code 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing).

Radiation treatment codes for prostate cancer include an injection of a radioactive element, 55859, and the base code for insertion of a radioactive substance, 55860. Codes 55862 and 55865 indicate whether the procedure included other structures.

Other procedures coders can expect to see are cryotherapy (55873), injections of chemotherapy (96400), and orchiectomy (54520) when the cancer involves the scrotum and testes.

Hormone replacements and other supplies should be coded J9217 (Leuprolide acetate [for depot suspension], 7.5 mg), J9219 for a Lupron implant (Leuprolide acetate implant, 65 mg), and J9202 for an implant of Zoladex (Goserelin acetate implant, per 3.6 mg).  

Don't Code Robotic Procedures Any Differently

Robotic surgery is now available to urologists performing prostatectomies. To code for the laparoscopic radical prostatectomy using robotic surgery, simply use 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing). You need not append modifier -22 (Unusual procedural services).

For example, urologists perform a robotic radical laparoscopic prostatectomy with bilateral lymph node dissection. Nicki White, CPC, at a practice in Nashville, Tenn., coded it 55866 and 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) with modifier -51 (Multiple procedures) appended, with a diagnosis of 185 (Malignant neoplasm of prostate).