Urology Coding Alert

Plus, make sure you know when to support your coding with V76.44.

Prostate specific antigen (PSA) tests are often commonplace in a urology practice.Determining the proper code to report can be a challenge, however. Your key to proper coding lies in your ability to distinguish a screening PSA test from a diagnostic PSA test. Follow these expert tips to ensure youre choosing the right codes every time.

Differentiate Screening From Diagnostic

Screening: You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test [PSA]). Some other payers follow these same guidelines.

Medicare requires that all yearly screening PSAs be billed with G0103, says

Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio.

Diagnostic: The correct code for a diagnostic PSA test is 84153 (Prostate specific antigen [PSA]; total), says Teresa A. Dailey, CPC, coding specialist for Urology Center of Spartanburg in South Carolina.

84153 is a diagnostic code, and would be used when there is an established disease/illness process which is outlined in the LCD [local coverage determinations] for that CPT code, explains Dan Rogers, administrator for Biloxi Bay Urology Center PLLC and Gulf South Urology in Biloxi, Miss.

I would bill 84153 when a diagnostic PSA is needed for another medically necessary reason; for example, observation of a rising PSA or a confirmed diagnosis of prostate cancer that requires the PSA be done after treatment has been initiated to assure its effectiveness, Hollingshead says.

Look for documentation clues: A coder can identify which CPT code to report by looking at the patients diagnosis in the medical record, says Laura Cwiklinski, office manager at Urology Partners Inc. in Cleveland -- but the physician shares the responsibility,she says. The coder needs to be able to identify the patient diagnosis within the physician notes. This will allow the coder to know what CPT code should be used. Its the responsibility of the physician to be specific when charting the patients diagnosis in the chart.

Use Dx to Support Your Code Choice

When your urologist orders a screening PSA test for a patient with no signs or symptoms of disease, you should use diagnosis code V76.44 (Special screening for malignant neoplasms; other sites; prostate) as the reason for the test.

If you code another diagnostic diagnosis with the G0103, Medicare will not pay for it, Cwiklinski says. You must use a screening CPT [code] with a screening ICD-9.

Official word: CMSs The Guide to Medicare Preventive Services manual (which can be found online at www.cms.hhs.gov/mlnproducts/downloads/psguid.pdf) elaborates on this requirement: There are no specific diagnosis requirements for prostate screening tests and procedures. However, if screening is the reason for the test and/or procedure, the appropriate screening (V) diagnosis code must be chosen when billing Medicare. The screening diagnosis code of V76.44 (Special screening for malignant neoplasms, prostate) is reported.

Hopeful news: According to some newer LCDs you would get paid with another diagnosis with the G0103,Rogers says. I would still continue to use the V76.44 if appropriate, but the new coverage determinations allow you to code PSA screenings with diagnoses such as benign prostatic hyperplasia (BPH, 600.00 or 600.01) and others,Rogers explains.

Check with your payer: The covered diagnoses for PSA test vary from payer to payer, Cwiklinski cautions.Each payer will have a list of acceptable, covered diagnoses. If you bill within these codes list, you will not have any denials, she adds. Regardless of the payers coverage determinations, you need to be sure that you have documentation to support your diagnosis choice,Hollingshead stresses.

Diagnose elevated PSA: When the urologist orders a diagnostic PSA test and the documentation specifies that the test result shows an elevated PSA, you should report 790.93 (Elevated prostate specific antigen [PSA]) as the diagnosis.

If the test results are normal, you would report the BPH as the reason for the test. Because you must report the BPH code to the fifth digit, youll have to know whether the patient has a urinary obstructionor is symptomatic so you can select the proper code as follows:

" 600.00 -- Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS)

" 600.01 -- Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS).

Alternative: If the ordering physician documents a more specific diagnosis, such as prostate cancer, you should report the appropriate code (185, Malignant neoplasm of prostate). Or if the physician only noted signs and symptoms, you should report that condition, such as 788.64 (Urinary hesitancy). According to recent LCDs,Medicare considers many ICD-9 codes indicating urological signs or symptoms -- such as 599.71 (Gross hematuria), 599.72 (Microscopic hematuria), 788.41 (Urinary frequency), or 788.43 (Nocturia) -- as payable diagnoses for PSA determinations.

Obey Once-a-Year Coding Limits

Medicare only pays for one screening PSA per year,stresses Gaye Pratt, coder/biller for Dr. Vincent P.Miraglia in Stuart, Fla. But Medicare (and other payers) may reimburse you for as many diagnostic PSAs per year as the patient needs, as long as you have a payable diagnosis, Pratt adds.

In my opinion, the biggest pitfall for screening PSAs is the timing, Hollingshead says. It is covered only once every 12 months for Medicare, with most commercial payers following suit. You need to make sure that you have at least 366 days (367 for leap years) between screening PSAs, she confirms.

Watch out: Make sure youre not just checking your own practices medical record. You should check to see if the patient has had a PSA screening at another office within the last year. On occasion we have had patients that have had a PSA done at another doctors office, such as the primary care doctor, then we draw a screening PSA and Medicare denies it due to the fact that Medicare will only pay for one screening PSA a year, Dailey cautions.

Self-pay option: If the patient wants or needs a screening PSA test before the one-year time limit is up, your best bet is to have the patient sign an advance beneficiary notice (ABN) agreeing to pay for the test himself.

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Typically you cannot use a blanketABN; however,you may be able to have the patients sign one stating that if they had the test done elsewhere within the allowed timeline,they will be responsible for payment, Rogers says.