Urology Coding Alert

Question: We’ve been getting denials for claims once we began using the new ICD-10 code R97.20. Do you know the reason for this?

Illinois Subscriber

Answer: You are not alone in receiving Medicare denials for R97.20 (Prostate specific antigen [PSA]. Although this ICD-10 coding change was reported on October 1, 2016 and was to be effective on Oct. 1, 2016, according to Medicare’s National Coverage Determination ID #190.28, Medicare will not recognize this new diagnosis code until Jan. 3, 2017. In the meantime, you can still submit your claim with R97.2 (Elevated prostate specific antigen [PSA]). Begin using R97.20 (Elevated prostate specific antigen [PSA]) for Medicare in January.

Many non-Medicare carriers have also adopted this policy. However, since some payers will require R97.20 now, be sure to watch for and correct any non-payments before January 3, 2017, when using either R97.2 or R97.20.