Urology Coding Alert

Screening PSAs are only covered once a year.

Your urologist probably performs multiple prostate specific antigen (PSA) tests in your practice. However, if you don’t know whether the test was diagnostic or screening and you don’t know which ICD-10-CM codes you should rely on, you could be facing denials.

Answer the following questions to always submit clean claims in your practice.

Find Reason Behind Order

Question 1: What CPT^® code should I report if my urologist orders a PSA test?

Answer 1: You have several different codes to choose from if your urologist orders a PSA test. To choose the appropriate code, you will need to know whether your urologist ordered the test for screening or diagnostic purposes.

Screening test: If your urologist ordered a screening PSA for a Medicare patient, you should report G0103 (Prostate cancer screening; prostate specific antigen test (PSA)). Since some other payers follow these same guidelines, you need to check with each of your payers to learn their individual rules.

In this screening examination, your urologist 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.

Diagnostic test: On the other hand, if your urologist orders a diagnostic PSA test from a clinical laboratory, you should choose from the following three codes based on the type of test they requested:

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

Coding tip: You should check your urologist’s medical documentation to determine whether the PSA is screening or diagnostic. If you don’t see signs or symptoms in the notes that indicate the patient is having a urological/prostate problem, in other words if the patient is asymptomatic, you should report G0103.

However, if your urologist orders the PSA test because he suspects prostate cancer due to a firm feeling of the prostate gland he found during a rectal examination, the test is diagnostic, and you should report 84153.

Turn to These ICD-10-CM Codes for PSAs

Question 2: What are the ICD-10-CM codes for PSA tests?

Answer 2: For a screening test (G0103) for a patient with no signs or symptoms of disease, you should report code Z12.5 (Encounter for screening for malignant neoplasm of prostate).

On the other hand, when your urologist orders a diagnostic PSA test and the documentation specifies that the test result shows an elevated PSA, you should report code R97.20 (Elevated prostate specific antigen [PSA]).

If the patient’s test results are normal, you should report either N40.0 (Enlarged prostate without lower urinary tract symptoms) or N40.1 (Enlarged prostate with lower urinary tract symptoms).

Don’t miss: If your urologist documents a more specific diagnosis, like prostate cancer, you should report the appropriate code — C61 (Malignant neoplasm of prostate).

If your urologist only notes signs and symptoms, you can report an ICD-10-CM code like R39.11 (Hesitancy of micturition). Medicare considers several ICD-10-CM codes indicating urological signs and symptoms as payable for PSA tests. Some of these are as follows:

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

Coding tip: Since the covered diagnoses for a PSA test vary from payer to payer, each payer will have a list of acceptable covered diagnoses. You should always check your payer’s list to make sure the diagnosis you chose is on their list of acceptable diagnoses, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.

Mind Screening PSA Time Limit

Question 3: How many screening PSAs does Medicare allow for each year? Are there any limits on diagnostic PSAs?

Answer 3: Medicare only pays for one screening PSA per year. However, Medicare and other payers may reimburse you for as many diagnostic PSAs per year as the patient needs if you have a documented payable diagnosis and medical necessity.

Coding tip: When you are checking to see how many screening PSAs the patient has had within the last year, you should check all practices they have been to, not just your urology practice. For example, if your patient had a screening PSA done at their primary care provider, your payer will deny a second screening PSA performed at your urology practice.

However, the patient could choose to self-pay for a screening PSA before the one-year time limit is up. In this case, you should get the patient to sign an advance beneficiary notice (ABN) stating they understand their insurance does not cover the service and they are planning on paying the bill out of pocket.

Treat E/M During PSA This Way

Question 4: My urologist performed a separate evaluation and management (E/M) service during the same encounter as the PSA. Can I report both the E/M service and the PSA?

Answer 4: Yes. You should be able to separately report the PSA test code and the appropriate E/M code based on the level of service your urologist documented. You should not need to append 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 because a global period does not apply to PSA laboratory tests.