Urology Coding Alert

The diagnosis code you choose will make or break your claim.

When your urologist performs a prostate specific antigen (PSA) test, your coding isn't as simple as just assigning one code. First, you need to determine the type of test your physician performed and then the payer you're reporting to.

Make sure you're choosing the proper codes and assigning the proper diagnoses by learning these three expert guidelines for your PSA claims.

1. Base Coding on Screening vs. Diagnostic

When your urologist performs a PSA test, your code choice will depend on the PSA test's purpose. Medicare, and some other payers, require that you code screening PSA tests one way and diagnostic tests another.

Screening: For a screening PSA for a Medicare beneficiary you'll report G0103 (Prostate cancer screening; prostate specific antigen test [PSA]), says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. Some other payers follow these same guidelines.

Diagnostic: In contrast, if the PSA test is for diagnostic purposes you'll have three codes to choose from:

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

Most of the time you'll report 84153, regardless of the payer. You'll rarely use 84152, and you won't use 84154 unless there is a known PSA elevation.

"84153 is the only code that we have used in our practice for coding of our diagnostic PSAs," Hines confirms.

Remember: You may use G0103 or 81452 with E/M codes for separate E/M services which your urologist performs during the same encounter, advises Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

2. Let the Diagnosis Prove Your Procedure Coding

You will be able to quickly identify whether to use G0103 or 84153 by reviewing your urologist's documentation. Report G0103 when your urologist orders a PSA test for a patient without signs or symptoms of a problem. But if your urologist performs the test for a patient because he suspects carcinoma, for example, due to clinical findings, you would use 84153.

"The diagnostic ICD-9 code for G0103 should be V76.44 (Special screening for malignant neoplasms; prostate)," Ferragamo says.

CMS's The Guide to Medicare Preventive Services manual (which can be found online at www.cms.hhs.gov/mlnproducts/downloads/psguid.pdf) elaborates on this requirement: "There are no specific diagnosis requirements for prostate screening tests and procedures. However, if screening is the reason for the test and/or procedure, the appropriate screening ('V') diagnosis code must be chosen when billing Medicare."

There are several ICD-9 codes you might use for a diagnostic PSA test (84153), Hines says -- such as malignant neoplasm of prostate (185), gross hematuria (599.71), or elevated PSA (790.93). "Always make sure that it is a valid diagnosis to cover the reason for the PSA," she stresses.

You may also use the symptoms the patient presented with, such as incomplete bladder emptying (788.21), grossly bloody urine (599.71) or urinary frequency (788.41).

3. Watch For Frequency Limits

Medicare covers screening PSA tests once every 12 months for men age 50 years and older, Hines warns. So be sure at least 11 months have passed since the patient last had a PSA screening.

Potential snag: Make sure you're not just 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. Otherwise, there will be times when your patient will have had a screening PSA at another doctor's office, such as the primary care doctor, and your PSA claim will be denied based on this previous PSA performed within that year.

Alternative: If the patient wants or needs a screening PSA test before the one-year time limit has passed, your best bet is to have the patient sign an advance beneficiary notice (ABN) agreeing to pay for the test himself if the carrier denies payment because of a recently performed PSA determination.

Golden rule: 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, Hines says.