Urology Coding Alert

Question: What are the rules for coding prostate cancer screenings? Can we report E/M services in addition to screenings? Or are E/Ms considered included in codes G0102 and G0103? Does appending modifier -25 to the E/M make a difference?

Iowa Subscriber

Answer: When a Medicare patient presents only for a prostate screening, two codes one CPT and one ICD-9 are required for reimbursement. Specifically, you must link the diagnosis code V76.44 (Special screening; prostate) to one of Medicare's two HCPCS codes, G0102 (Prostate cancer screening; digital rectal examination) and G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total) depending on the type of screening performed.

When reporting prostate screenings, you should not report additional E/M services unless an E/M service has been performed for an entirely different problem that is represented in a separate diagnosis code linked to the E/M code. For this case, your E/M service will include the digital rectal examination, and code G0102 should never be billed in addition. Do not use the ICD-9 diagnosis code V76.44 with any E/M service or code. Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is never required when billing an E/M service and code G0103 for a screening PSA. However, the latter code mandates ICD-9 diagnosis code V76.44.

Answers to You Be the Coder and Reader Questions contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 19-urologist practice in Indianapolis.