Prostate Cancer Screening Essentials for Coders/Billers

Prostate Cancer Screening Essentials for Coders/Billers

September is Prostate Cancer Awareness month. Before you absentmindedly produce a claim for prostate cancer screening, take a moment to understand this disease.

Prostate Cancer Basics

Prostate cancer is the most common cancer in American men, according to the Centers for Disease Control and Prevention.

The prostate is a part of the male reproductive system. Its job is to produce fluid that makes up a part of semen. Risk factors for prostate cancer include age, family history, and race.

Symptoms of prostate cancer may include:

  • Difficulty starting urination
  • Weak or interrupted flow of urine
  • Frequent urination, especially at night
  • Difficulty emptying the bladder completely
  • Pain or burning during urination
  • Blood in the urine or semen
  • Pain in the back, hips, or pelvis that persists
  • Painful ejaculation

Symptoms or no, the American Cancer Society recommends that men age 50 and older be screened for prostate cancer. The recommended age for screening to begin in men with family history of prostate cancer and black men is 45.

Two tests are commonly used to screen for prostate cancer:

  • Digital rectal exam (DRE): A qualified healthcare professional inserts a gloved, lubricated finger into the patient’s rectum to estimate the size of the prostate and feel for lumps or other abnormalities.
  • Prostate-specific antigen (PSA) test: This is a blood test that measures the level of PSA, a substance made by the prostate. An elevated PSA could be an indication of prostate cancer.

Coding/Billing for Prostate Cancer Screening

Medicare provides coverage of an annual preventive prostate cancer screening DRE and PSA blood test for all male beneficiaries age 50 and older. At least 11 months must have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed. There is no deductible or coinsurance/co-payment for the PSA text, but there is for the screening DRE under Medicare Part B.

Report HCPCS Level II code G0102 Prostate cancer screening; digital rectal examination or G0103 Prostate cancer screening; prostate specific antigen test (PSA), total, as appropriate, with ICD-10-CM diagnosis code Z12.5 Encounter for screening for malignant neoplasm of prostate (ICD-9-CM V76.44 Special screening for malignant neoplasms, prostate).

For Medicare beneficiaries, code G0103 is paid under the Clinical Diagnostic Laboratory Fee Schedule; and G0102 is paid under the Medicare Physician Fee Schedule.

Note: You may not bill separately for a DRE when performed on the same day as an evaluation and management service (CPT® codes 99201-99456 and 99499).

 

Source: MLN Matters® article: SE0709

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 423 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

2 Responses to “Prostate Cancer Screening Essentials for Coders/Billers”

  1. Samantha Prince says:

    It would be wonderful and helpful if the AAPC could add a PDF button to download the file in PDF format for later use/retrieval

  2. Susan Powell MD says:

    Prostate cancer is not the most common type of cancer in men – skin cancer is. Prostate cancer screening is controversial. What the American Cancer Society recommends is that men have a DISCUSSION with their doctor about screening for this type of cancer, not that they actually be screened. Perhaps it would be helpful from a coding perspective to discuss what codes are appropriate when the physician counsels the patient about screening, but does not actually do or order a screening test. More often than not, this counseling will not lead to actual screening.

    See below from Up To Date:

    The United States Preventive Services Task Force Guidelines [171], American College of Physicians [172], American Urologic Association [173], American Cancer Society [46], and the Canadian Task Force on the Periodic Health Examination [174] all stress the importance of informed decision making.

    The American College of Physicians and the American Cancer Society have provided useful summaries of discussion points to consider when counseling patients about prostate cancer screening [46,172,175]:

    ●Prostate cancer is an important health problem; it is one of the most frequently diagnosed cancers in the United States and a leading cause of cancer death in men.
    ●Prostate cancer screening is controversial, and men should be involved in making the decision whether or not to be screened.
    ●Prostate cancer screening may reduce the chance of dying from prostate cancer. However, the evidence is mixed and the absolute benefit is small. For most men, the chances of harm from PSA screening outweigh the benefits.
    ●Most men who choose not to have PSA testing will not be diagnosed with prostate cancer and will die from some other cause.
    ●In order to determine whether a cancer is causing an abnormal test, men need to undergo a prostate biopsy. However, the PSA test and digital rectal exam (DRE) can both have false-positive and false-negative results. Prostate biopsies may also miss finding cancers and can rarely cause serious infections.
    ●Patients who choose PSA testing are much more likely than those who decline PSA testing to be diagnosed with prostate cancer. Many cancers detected by screening are considered “overdiagnosed”, meaning that they never would have caused problems during a man’s lifetime.
    ●No current tests can accurately determine which men with a cancer found by screening are most likely to benefit from aggressive treatment (ie, those whose cancers are destined to cause health problems). Most men with prostate cancer will die from other causes; many will never experience health problems from their cancer.
    ●Aggressive therapy is necessary to realize any benefit from finding an early-stage prostate cancer, however, studies show that only men with high PSA or Gleason score are likely to benefit.
    ●Surgery and radiation therapies are the treatments most commonly offered in an attempt to cure prostate cancer; however, they can lead to problems with urinary, bowel, and sexual function.
    ●A strategy of active surveillance may be appropriate for men who are at low risk for complications from prostate cancer (PSA <10 ng/mL and Gleason <7). This means not immediately treating a cancer but following PSA tests, DRE, and repeating biopsies to determine whether aggressive treatment is indicated because the cancer is progressing [176].
    Clinicians find it challenging to provide comprehensive, consistent, and balanced information about prostate cancer screening decisions during clinic visits [12,177]. Consequently, efforts have focused on using decision support tools to help patients understand screening issues and make informed decisions for screening [178,179].

    Investigators have evaluated a number of interventions to facilitate such informed prostate cancer screening decisions including videotapes [180-182], patient group discussions [180], brief scripts read to patients during clinic visits [183], verbal and written material provided before a periodic health examination [184], and informational pamphlets distributed at study visits [185] or through the mail [186].

    Current websites providing decision support tools include:

    ●American Cancer Society (ACS)
    ●American Society of Clinical Oncology (ASCO)
    ●Cardiff University
    ●Centers for Disease Control and Prevention (CDC)
    ●Mayo Clinic
    The content of a screening discussion or the provision of a decision aid should be documented in the medical record, particularly when the patient decides against screening.

    A systematic review of 18 trials of patient decision aids for prostate cancer screening found that decision aids consistently improved patient knowledge about prostate cancer and screening, increased participation in decision making, and made patients more confident about their decisions [187]. Receiving a decision aid generally decreased intention to be screened and resulted in lower screening rates among patients coming for routine office visits (relative risk 0.88, 95% CI 0.81-0.97). Similarly, in a subsequent large randomized trial, decision aids increased patient knowledge and decisional satisfaction and decreased decisional conflict, however, they had no effect on actual rates of screening [188].

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