3 Tips for Proper PSA Test Coding
Get to the correct code with the help of the urologist’s diagnosis.
Prostate specific antigen (PSA) screenings are commonplace in most urology practices, which means if you don’t have your procedure and diagnosis coding straight, you may face high denial rates and possibly significant revenue loss. Avoid those pitfalls with these three tips.
TIP 1 – Determine Screening or Diagnostic
When the urologist documents that they performed a PSA test, dig a bit deeper. Some payers, including Medicare, have different coding requirements for screening and diagnostic PSA tests.
For a Medicare patient, report a screening PSA with G0103 Prostate cancer screening; prostate specific antigen test (PSA) and a diagnostic PSA with one of the following three codes (based on the type of test):
84152 Prostate specific antigen (PSA); complexed (direct measurement)
84153 Prostate specific antigen (PSA); total
84154 Prostate specific antigen (PSA); free
Pointer: Most often, urology practices perform PSA testing that correlates to CPT® 84153. You’ll rarely use 84152, and you’ll only use 84154 if there is a known PSA elevation.
You can quickly identify whether to use G0103 or 8415X by reviewing the urologist’s notes. If you don’t see signs or symptoms in the notes that indicate the patient is having a urological/prostate problem — in other words, the patient is asymptomatic — use G0103. If, instead, the urologist orders the test and documents the patient as having, for example, a firm-feeling prostate gland on rectal examination, the PSA test is diagnostic, and you should use 84153.
If the urologist performs a separate evaluation and management (E/M) service during the same encounter as the PSA test, you should be able to separately report the PSA test code and the appropriate E/M code (based on the documented level of service). You should not need modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service on the E/M service, as a global period does not apply to the PSA laboratory test.
TIP 2 – Choose the Supporting Diagnosis Codes
For a screening test for a patient with no signs or symptoms of disease, use diagnosis code Z12.5 Encounter for screening for malignant neoplasm of prostate. If you report another diagnosis code with G0103, Medicare will not pay for it. You must use a screening diagnosis with a screening CPT® code.
When the urologist orders a diagnostic PSA test and the documentation specifies that the test result shows an elevated PSA, report diagnosis R97.20 Elevated prostate specific antigen [PSA].
If the test results are normal, however, one of the following benign prostatic hyperplasia (BPH) codes may be appropriate:
N40.0 Benign prostatic hyperplasia without lower urinary tract symptoms
N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms
If the ordering physician documents a more specific diagnosis, such as prostate cancer, report the appropriate code (for example, C61 Malignant neoplasm of prostate). Or if the urologist only notes signs and symptoms, codes such as R39.11 Hesitancy of micturition may apply. Medicare will consider many diagnosis codes indicating urological signs or symptoms as payable for PSA determinations, such as:
R31.0 Gross hematuria
R31.1 Benign essential microscopic hematuria
R35.0 Frequency of micturition
This, of course, is a short list. Each payer has their own list of acceptable covered diagnoses.
TIP 3 – Watch Out for Frequency Limits
Once you decide on the codes, there’s one more point to check before submitting the claim: Payers have tight restrictions on the frequency for which they will pay for PSA tests.
Medicare, for example, covers screening PSA tests once every 12 months for men age 50 years and older, as instructed in the Claims Processing Manual, Chapter 18, Section 50.
Be sure at least 11 months have passed since the patient last had a PSA screening — and that doesn’t mean the last time the rendering urologist ordered the screening PSA. If the patient had another screening PSA at another practice, such as their primary care physician’s office, that counts toward frequency limits and your claim will be denied if the other test was within one year of your claim.
A patient may need or want a screening PSA before the one-year mark has passed, and you don’t have to lose the cost of that test. You should, however, know this before the test so you can have the patient sign an advance beneficiary notice (ABN), agreeing to pay for the test themselves if the payer denies the claim based on testing frequency.
Check the payer’s guidelines and local coverage determinations (LCDs) to learn their screening frequency limits and acceptable diagnostic codes for both screening and diagnostic PSA testing. As usual, regardless of the payer’s coverage determinations, there must be documentation in the patient’s record to support your coding.
Medicare Claims Processing Manual, Chapter 18, section 50, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18pdf.pdf