Urology Coding Alert

Tip: Look to ‘G’ code for Medicare patient screening.

Prostate specific antigen (PSA) testing might be one of the most common procedures in your urology practice, but that doesn’t mean you always have a cut-and-dry way to code the encounter. Your diagnosis coding is just as important to your claim’s success as the test code. Follow these four steps to ensure you know the ins and outs of PSA coding to keep your claims from coming back unpaid.

Step 1: Check Why the Test Was Performed

CPT^® includes two procedure codes that you may choose for a PSA test. The choice you make will depend on the reason your urologist ordered the test.  

Option 1: You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test (PSA)). Some other payers follow these same guidelines, so you need to check with each of your payers to learn their individual rules.

In this screening examination, the provider detects the PSA level in a patient’s blood. PSA is a protein the prostate gland produces; providers may use PSA levels to screen for prostate cancer.

Option 2: However, if the urologist orders a diagnostic PSA test from a clinical laboratory, you will not report G0103. Instead, choose from the following three codes based on the type of test requested:

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

Urology practices most often 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, and 84153 is used to screen the total PSA results,” says Becky Boone, CPC, CUC, CPMA, senior urology surgery coder at The Coding Network, LLC in Columbia, Mo.

Consulting your urologist’s documentation is the only way you’ll know whether to code a screening or a diagnostic PSA test.

“To be eligible for a screening PSA, the patient should have no prior history of prostatic carcinoma and no signs or symptom suggestive of that diagnosis. A screening PSA is payable once every year,” says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

“Diagnostic PSA tests, such as 84152, 84153, and 84154 have a wide range of acceptable diagnoses,” Ferragamo adds. These can include R97.20 (Elevated prostate specific antigen (PSA)), R97.21 (Rising PSA following treatment for malignant neoplasm of prostate), and manyother clinical diagnoses as long as medical necessity is proven.

Quick check: 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.

Step 2: Match the Diagnosis to the Reason

For a screening test for a patient with no signs or symptoms of disease, you should use diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate).

If you report another diagnosis code with the G0103, Medicare will not pay for it. You must use a screening diagnosis with a screening CPT^® code.

When the urologist orders a diagnostic PSA test, and the documentation specifies that the test result shows an elevated PSA, you should report diagnosis R97.20.

If the test results are normal, however, you may report one of the following benign prostatic hyperplasia (BPH) codes:

• N40.0 (Enlarged prostate without lower urinary tract symptoms)
• N40.1 (Enlarged prostate with lower urinary tract symptoms).

Alternative:  If the ordering physician documents a more specific diagnosis, such as prostate cancer, you should report the appropriate code (for example, C61, Malignant neoplasm of prostate). Or if the urologist only noted signs and symptoms, you may wish to report that condition with an ICD-10-CM diagnosis such as R39.11 (Hesitancy of micturition), Ferragamo says. Medicare will consider many diagnosis codes indicating urological signs or symptoms as payable for PSA determinations. They may include:

• R31.0 (Gross hematuria)
• R31.1 (Benign essential microscopic hematuria)
• R35.0 (Frequency of micturition)
• R35.1 (Nocturia).

Check with your payer: The covered diagnoses for a PSA test vary from payer to payer. Each payer will have a list of acceptable covered diagnoses. If you bill any code within this list, you should not face denials. Regardless of the payer’s coverage determinations, you need to be sure that you have documentation to support your diagnosis choice.

Step 3: Be Wary of Annual Coding Limits

Medicare only pays for one screening PSA per year. But Medicare (and other payers) may reimburse you for as many diagnostic PSAs per year the patient needs, if you have a documented payable diagnosis and medical necessity.

Caution: Make sure you are not only checking your own practice’s medical record. You should check to see if the patient has had a PSA screening at another office within the last year. You may occasionally find patients that have had a PSA done at another doctor’s office, such as their primary care provider. If you then bill a second screening PSA, the payer will deny your claim.

Self-pay option: “If the patient wants or needs a screening PSA test before the one-year time limit is up, your best bet is to have the patient sign an advance beneficiary notice (ABN) agreeing to pay for the test himself if the payer refuses to reimburse for the earlier than usual PSA,” Ferragamo says.

Step 4: Check Whether Z Codes Apply

ICD-10 includes Z codes that indicate when a patient has a personal or family history of illness that may impact current healthcare decisions, even though the patient doesn’t currently have the illness. You’ll often use personal history codes with codes for follow-up after disease treatment is complete. You also might use family history codes with screening codes to explain the need for a test or procedure. Two highly common examples are Z80 (Family history of primary malignant neoplasm) and Z85 (Personal history of malignant neoplasm). Both diagnostic codes will require increased specificity.

For instance: If the lab performs a PSA test (such as 84153) more than a year after successful treatment for a prostate cancer patient, you should not use a prostate cancer diagnosis (C61). Instead, you should report Z85.46 (Personal history of malignant neoplasm of prostate). For a family history of prostatic cancer, use Z80.42 (Family history of malignant neoplasm of prostate). Mislabeling the patient as an active cancer patient could affect his ability to get health or life insurance or affect his treatment by other physicians for other conditions.

“There are a few Z codes that can be used only as first-listed diagnoses,” states Dee Mandley, RHIT, CCS, CCS-P, president of D. Mandley & Associates, LLC in Stow, Ohio. You can find these at the ICD-10-CM Official Guidelines for Coding and Reporting Section 1; C; 21; 16, found at www.cms.gov/Medicare/Coding/ICD10/Downloads/2017-ICD-10-CM-Guidelines.pdf.

Final 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 tests.