Urology Coding Alert

Question: My doctor is doing a test called PSA3. We are considering doing this in our facility. However, along with this test, a prostatic massage is required. Is there a code for this, or is it included with the E/M service?

California Subscriber

Answer: You should include the prostatic massage within the E/M service you report. This will not be a separately reportable service.

However, if the urologist does a microscopic examination of the prostatic secretions (known as a wet smear), you should bill for that service using 87210 (Smear, primary source with interpretation; wet mount for infectious agents [e.g., saline, India ink, KOH preps]).

Note: You'll need to append modifier QW (CLIA waved test). To use this modifier, your physician must have a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA).

Don't forget: In addition to appending modifier QW, be sure to write your CLIA waiver number in item 23 of the CMS-1500 form.

Alternative: Use 87205 (Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types) if the physician does a microscopic examination of a stained smear of the prostatic secretions.