Urology Coding Alert

Your first step: Differentiate diagnostic tests from screening tests

When your urologist performs a prostate specific antigen (PSA) test, don't make the mistake of automatically coding 84153. Although 84153 is the most common PSA code for diagnostic testing, you actually have four CPT Codes to choose from and very specific carrier guidelines to adhere to before reporting them.

PSA tests are common in urology offices, and confusion over how to report the test is common among urology coders. Knowing when you cross over into diagnostic testing, instead of screenings, is key.

Make sure you're choosing the proper codes and assigning the proper diagnoses by following these expert answers to your top PSA coding questions.

1. Beware of Specific Screening Requirements

Your code choice will depend on the PSA test's purpose. Medicare requires different coding for screening and diagnostic PSA tests. For a screening PSA, turn to the HCPCS codes, and report G0103 (Prostate cancer screening; prostate specific antigen test [PSA]).

When the urologist orders a PSA test for diagnostic purposes, however, you'll use one of the following three CPT codes, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis:

• 84152--Prostate specific antigen (PSA); complexed (direct measurement)
• 84153--Prostate specific antigen (PSA); total
• 84154--Prostate specific antigen (PSA); free.

Note: You'll rarely use 84152, and you won't use 84154 unless there is a known PSA elevation, Hause says.

How it works: CMS defines screening as "testing for disease or disease precursors so that early detection and treatment can be provided for those who test positive for the disease." You report G0103 when your urologist orders a PSA test for a patient without signs or symptoms of a problem. But if your urologist performs the test for a Medicare patient because he suspects carcinoma, for example, due to clinical findings, you would use 84153.

Remember: Medicare covers screening PSA tests once every 12 months for men age 50 years and older, so be sure at least 11 months have passed since the patient last had a PSA screening.

2. Use V Code, Not BPH Code, for Screenings

Diagnostic and screening PSA tests also have different diagnosis requirements for Medicare reimbursement. Knowing the differences can mean proper payment--or a multitude of denials. "With all of the payable diagnosis codes for PSAs, there is really no reason for denials," says Jennifer Sikkink, CPC, of Urology Specialists in Sioux Falls, S.D.

When your urologist orders a screening PSA when the patient has no prostate symptoms, you should not report any of the ICD-9 codes from the National Coverage Determination (NCD) list of covered diagnoses. Instead, you should bill Medicare for a screening PSA using diagnosis code V76.44 (Special screening for malignant neoplasms; prostate), Sikkink says.

Medicare covers a diagnostic PSA test (84153) 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).

Bonus: As of last October, you're also able to prove medical necessity for PSA tests using BPH without obstruction (600.00) and prostate nodule (600.10 and 600.11). For a complete listing of the payable codes, visit www.cms.hhs.gov/CoverageGenInfo/downloads/manual200704.pdf#20.

PSA, a prostate cancer marker, exists in the blood in two forms: "complexed" (bound) to a protein or "free." Medicare only reimburses the diagnostic PSA tests 84152 and 84154 with ICD-9 diagnosis 790.93 (Elevated prostate specific antigen [PSA]).