Urology Coding Alert

Hint: The diagnosis can point you in the right direction.

Prostate specific antigen (PSA) screenings are commonplace in most urology practices, which means if you don’t have your procedure and diagnosis coding straight, you may face high denial rates and possibly significant revenue loss.

Just because ICD-10 changed the codes you’ll use to support the CPT® codes you report, that doesn’t mean your job has to get harder. Read on to get the expert advice to help you successfully code PSA tests from start to finish.

Start By Selecting Screening or Diagnostic

When your urologist documents that he performed a PSA test, you’ll need to dig a bit deeper.

Here’s why: Some payers, including Medicare, will have you report a screening PSA test different than when you report a diagnostic PSA test.

For a screening PSA for a Medicare beneficiary, report G0103 (Prostate cancer screening; prostate specific antigen test [PSA]), says Becky Boone, CPC, CUC, CPMA, senior urology surgery coder at The Coding Network, LLC in Columbia, Mo. Some other payers follow these same guidelines, so you need to check with each of your payers to learn their individual rules.

If your urologist orders the PSA test for diagnostic purposes, however, you won’t use the G code. Instead, you’ll choose from the following three codes based on the type of test:

• 84152 — Prostate specific antigen (PSA); complexed (direct measurement)
• 84153 — ... total
• 84154 — ... free.

Most often urology practices perform PSA testing that correlates to 84153. You’ll rarely use 84152, and you will only use 84154 if there is a known PSA elevation. “Code 84152 for the complex portion that is considered bonded to the proteins in the blood, 84154 is used to determine the 10 percent that is not bound to the protein as they use for the 84152 procedure, but 84153 is used to screen the total PSA results,” Boone explains.

Good news: You will be able to quickly identify whether to use G0103 or 8415X by reviewing your urologist’s notes. If you don’t see sign or symptoms in the notes that indicate the patient is having a urological/prostate problem — in other words, the patient is asymptomatic — you should choose G0103. If, instead, your urologist orders the test because he suspects prostate cancer due to a firm feeling prostate gland on rectal examination, the PSA test is diagnostic and you should use 84153.

Pointer: If your urologist performs a separate E/M service during the same encounter he performs the PSA test, you should be able to separately report the PSA test code and the appropriate E/M code based on the documented level of service. You should not need modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the E/M service as a global period does not apply to the PSA laboratory test.

Update Your Supporting Diagnosis Codes

Prior to Oct. 1, 2015 you used V76.44 (Special screening for malignant neoplasms; prostate) to support a screening PSA test. Now that you’re using ICD-10, you should use Z12.5 (Encounter for screening for malignant neoplasm of prostate), Boone says.

Official guidance: CMS confirms this requirement in Chapter 18 “Preventive and Screening Services” of the Medicare Claims Processing Manual (which can be found online at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf): “Prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using ... if ICD-10-CM is applicable, diagnosis code Z12.5.”

There are several ICD-10 codes you might use for a diagnostic PSA test (84153). Your urologist might document conditions such as malignant neoplasm of prostate (C61), gross hematuria (R31.0), or elevated PSA (R97.2). You may also use the symptoms with which the patient presented, such as incomplete bladder emptying (R39.14) or urinary frequency (R35.0).

Beware of Frequency Limits

Once you decide on a code, there’s one more point to check before you send out your claim. Payers have tight restrictions on the frequency for which they will pay for PSA tests.

Medicare, for example, covers screening PSA tests once every 12 months for men age 50 years and older, as instructed in the Claims Processing Manual: “Each test may be paid at a frequency of once every 12 months for men who have attained age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months have passed following the month in which the last Medicare-covered screening ... PSA test was performed.”

So be sure at least 11 months have passed since the patient last had a PSA screening. That doesn’t mean the last time your urologist ordered the screening PSA. If the patient had another screening PSA at another practice, such as his primary care physician’s office, that counts against you and your claim will be denied if the other test was within one year of your claim.

Don’t fret: For one reason or another, the patient may need or want a screen PSA before the one-year mark has passed.

You don’t have to lose the cost of that test if your urologist performs it. You should, however, know this before the test so you can have the patient sign an advance beneficiary notice (ABN) agreeing to pay for the test himself if the payer denies the claim based on testing frequency.

Bottom line: Check your payer’s guidelines and local coverage determinations (LCDs) to find out screening frequency limits and acceptable diagnostic codes for both screening and diagnostic PSA testing.