Coding Prostate Cancer Screening
Every 17 minutes another man dies from prostate cancer in the United States.
September is National Prostate Cancer Awareness Month and a great time to help raise awareness about this disease. Prostate cancer is the most common cancer and the second leading cause of cancer death among American men. In 2019, nearly 175,000 men will receive a diagnosis of prostate cancer, with an estimated 32,000 deaths from this disease by year’s end. Early detection is key to living prostate cancer-free; help spread the word and know how to code/bill for prostate cancer screening services.
Prostate Cancer Basics
Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate, a walnut-shaped gland that sits at the base of the bladder. Currently, there are nearly 3.1 million American men living with the disease and one in nine American men will have prostate cancer during his lifetime. Despite the startling number of men stricken with this disease, most men with prostate cancer survive it.
Increased age, race, and family history of the disease are the major risk factors. The chance of developing the disease dramatically increases at age 55 and is predominant in men over 65. For unknown reasons, the risk of prostate cancer is about 60% higher in African American men than in Caucasian American men. Prostate cancer usually grows very slowly, and early prostate cancer often causes no symptoms. By the time symptoms appear, cancer may have begun to spread. The goal of screening for prostate cancer is to find cancer early and treat it before it metastasizes.
The American Cancer Society recommends all men talk with their healthcare provider, so they can decide if prostate cancer screening is right for them. Men should have this talk at:
- Age 50: if they are at average risk for prostate cancer and are expected to live at least another 10 years.
- Age 45: if they are at high risk because they are African American or have a close relative (father, brother, or son) who had prostate cancer before age 65.
- Age 40: if they are at even higher risk of getting prostate cancer because more than one close relative had prostate cancer before age 65.
Screening for Prostate Cancer
Two tests commonly used to screen for prostate cancer:
- Digital rectal exam (DRE) is an exam of the rectum. A healthcare provider inserts a gloved, lubricated finger into the lower part of the rectum to feel the prostate for abnormalities such as cancer.
- Prostate-Specific Antigen (PSA) test is a test that measures the level of PSA in the blood. PSA is a substance made primarily by the prostate that may be found in an increased amount in the blood of men who have prostate cancer. Other conditions that affect the prostate, such as enlargement and infection and certain medications and medical procedures, also elevate PSA levels.
If the PSA test is higher than normal, the doctor may order a biopsy of the prostate to assist in diagnosis.
Coding/Billing Prostate Cancer Screening
Because the risk for prostate cancer increases with age, Medicare covers annual prostate cancer screening for all male beneficiaries 50 years 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.
For Medicare patients, report the following HCPCS Level II codes, as appropriate:
- G0102 Prostate cancer screening; digital rectal examination
- G0103 Prostate cancer screening; prostate-specific antigen test (PSA)
The ICD-10 diagnosis code to support either screening is Z12.5 Encounter for screening for malignant neoplasm of prostate.
There is no deductible or coinsurance/co-payment for the PSA test, but there is for the screening DRE under Medicare Part B.
For more information see National Coverage Determination 210.1