Urology Coding Alert

Question: What are Medicare's coverage criteria for PSA testing? Are both free and total PSA tests covered? Are the criteria different for screening and diagnostic testing?

Indiana Subscriber

Answer: Yes, diagnostic and screening prostate specific antigen (PSA) tests do have different criteria and codes for Medicare.

The diagnostic test -- 84153 (Prostate specific antigen [PSA]; total) -- is covered when the patient presents with symptoms, such as incomplete bladder emptying (788.21), bloody urine (599.7) or urinary frequency (788.41). Carriers also cover this test when urologists use it to monitor disease or treatment progression for conditions such as prostatitis (601.9) or prostate cancer (185).

Visit www.cms.hhs.gov/mcd/index_section.asp for a complete listing of the payable codes. (Note: BPH, 600.00, 600.01, etc., is not a payable diagnosis, but many of the symptoms of BPH are.) Report the diagnostic tests with one of three codes, depending on the PSA fraction measured:

PSA, a prostate cancer marker, is also found in the blood in two forms: "complexed" (bound) to a protein or "free." The diagnostic PSA tests -- complexed PSA, 84152 (Prostate specific antigen [PSA]; complexed [direct measurement]); and free PSA, 84154 (Prostate specific antigen [PSA]; free) -- are only reimbursed with ICD-9 diagnosis 790.93 (Elevated prostate specific antigen [PSA]).

Medicare will cover a PSA screening annually for men age 50 and older for the early detection of prostate cancer. The test is for men who present with no symptoms and with no clinical or laboratory findings suggestive of carcinoma of the prostate. In those cases, link G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total) to V76.44 (Special screening for malignant neoplasms; other sites; prostate).