Internal Medicine Coding Alert

Published on Mon May 01, 2000 PDF

Internists may want to encourage their patients to take advantage of two preventive benefits offered by Medicare. Effective Jan. 1, 2000, Medicare provides coverage of two screening tests for prostate cancer: the digital rectal exam (DRE) and the prostate specific antigen (PSA) test.

The two tests are thought to be complementary procedures that are relatively effective in diagnosing prostate cancer, according to Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the American Medical Associations (AMA) CPT editorial panel.

Use G-codes to Report Tests

A DRE is a clinical examination of an individuals prostate for nodules or other abnormalities. Internists should use G0102 (prostate cancer screening, digital rectal exam) to report this service. The Health Care Financing Administration (HCFA) announced in the Nov. 2, 1999, Federal Register that reimbursement for the DRE would be the same as the lowest level evaluation and management (E/M) service (99211).

The second benefit, the PSA blood test, detects the marker for adenocarcinoma of the prostate. For purposes of screening asymptomatic patients, Medicare has designated that G0103 (prostate cancer screening, PSA test) be used when asymptomatic patients are tested. The laboratory that processes the PSA blood test usually will bill this code rather than the internist who draws the sample. But the internist can use code G0001 (routine venipuncture for collection of specimen[s]) to report the blood draw, says Littenberg.

When the PSA blood test is performed on patients presenting symptoms, the diagnostic codes 84153 (prostate specific antigen; total) and 84154 (prostate specific antigen free) should be used. Reimbursement for code G0103 will be the same as for code 84153.

Both Tests Can Be Done Annually

The Medicare Carriers Manual section 4182 has some coverage requirements for the tests that must be met to receive reimbursement. Medicare provides coverage for these services to male beneficiaries aged 50 and older. The tests can be performed every 12 months, which means that at least 11 months must have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed. For example, if a beneficiary received a screening PSA in May 2000, the count would begin in June 2000. The beneficiary would be eligible to receive another PSA test in May 2001.

Both tests, however, can be done within the same one-year period, according to Littenberg. They can both be performed every 12 months, during the same visit or at different times, he notes.

In addition to the internist, a physicians assistant, nurse practitioner, clinical nurse specialist or clinical nurse midwife can perform the DRE or issue the order for the PSA. A written order for the PSA test must be placed in the patients medical record.

ICD-9 Diagnosis Codes Not Specified

Although a diagnosis code to indicate the medical necessity of the tests must be included in the claim, Medicare has not established a list of covered ICD-9 codes for the prostate cancer screening tests as it has done with other preventative services. Because Medicare did not specify ICD-9 codes for these tests, there may be some variability among carriers, advises Littenberg. Internists may want to read their local Medicare offices coding guidelines for these services before submitting a claim.

A look at the coding guidelines that are being published by some local carriers does indicate some differences in the diagnosis codes required. A medical policy for both screening and diagnostic prostate cancer tests issued by Blue Cross and Blue Shield of North Dakota (covering Alaska, Arizona, Hawaii, Nevada, Oregon and Washington) has a long list of covered diagnosis codes, none of which are particularly appropriate for the screening tests. On the other hand, Pennsylvania, Illinois, Michigan and Wisconsin all have coding guidelines that stipulate code V76.44 (special screening for malignant neoplasms; prostate) should be used for both screening tests.

DRE Bundled into E/M Service

HCFA stated in the Nov. 2, 1999, Federal Register that because the DRE is a relatively quick and simple procedure, the test will be bundled into payment for a covered E/M service when it is furnished on the same day as a DRE. If the DRE is the only service provided or is provided as part of an otherwise noncovered service, such as code 99397 (periodic preventive medicine reevaluation and management of an individual 65 years and over), then code G0102 would be separately payable.

If the patient comes for an office visit to discuss his hypertension and the internist decides to do the DRE at the same time, then it isnt separately reimbursable. If the patient comes in for the sole purpose of having the DRE, then it is, says Littenberg, who adds that this bundling into an E/M service may change in the future because several medical societies and local carriers are lobbying HCFA to change this policy.