Oncology & Hematology Coding Alert

Differentiate diagnostic vs screening.

Prostate specific antigen (PSA) testing may be a common encounter for you. Your physician may use PSA testing for both screening and diagnosis of prostate cancer. An important support to your claim will be the diagnosis codes that you submit. Gear up to prevent denials for your PSA claims. 

Check For Test Reason

You have two procedure codes to choose from for a PSA test, and which you choose will depend on the reason your oncologist ordered the test. 

Screening vs diagnosis: You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test [PSA]). Some other payers follow these same guidelines. On the other hand, for a diagnostic PSA test, you report 84153 (Prostate specific antigen [PSA]; total).

How do you confirm the diagnostic intent? Consulting your oncologist’s documentation is the only way you’ll know whether to code a screening or a diagnostic PSA test. 

To qualify for a screening PSA, your physician should document the patient never had a prostate cancer diagnosis. Additionally, the screening test can be performed on an annual basis. On the other hand, there isn’t any time restriction for the diagnostic PSA. Your physician can do PSA testing based on medical necessity for the purpose of diagnosis of the state of a current condition. “When the test is performed for diagnostic purposes, valid diagnoses for coverage may range from a known condition to determine the status of the disease or for various signs and symptoms,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. “CMS has a national coverage determination (NCD) policy explaining the limitations of coverage for both diagnostic and screening purposes.” See Medicare Publication 100-03:  National Coverage Determination (NCD) for Prostate Specific Antigen (190.31).

Match Diagnosis to Reason

For a screening test for a patient with no signs or symptoms of disease, you should use diagnosis code V76.44 (Screening for malignant neoplasms; other sites; prostate) which properly describes the reason for the test. With ICD-10-CM, you’ll report Z12.5 (Encounter for screening for malignant neoplasm of prostate).

If another diagnosis code is submitted with G0103, Medicare will not pay for it. Usually, V76.44 is the only code Medicare will allow for a screening PSA. If the physician suspects something else, the correct coding of the test may be a diagnostic PSA.

Official word: CMS’s Medicare Claims Processing Manual, Chapter 18 - Preventive and Screening Services, (which can be found online at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf) guides you on this requirement: “Prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using screening (‘V’) code V76.44.”

When the oncologist orders a diagnostic PSA test, and the documentation specifies the test result shows an elevated PSA, you should report 790.93 (Elevated prostate specific antigen [PSA]) as the diagnosis. When ICD-10-CM comes around, you’ll use R97.2 (Elevated prostate specific antigen [PSA]).

If the test results are normal, however, you may report one of the following benign prostatic hyperplasia (BPH) codes:

• 600.00 — Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) [ICD-10-CM: N40.0, Enlarged prostate without lower urinary tract symptoms]
  
• 600.01 — Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) [ICD-10-CM: N40.1, Enlarged prostate with lower urinary tract symptoms].
  

Alternative: If the ordering physician documents a more specific diagnosis, such as prostate cancer, you should report the appropriate code (185, Malignant neoplasm of prostate; ICD-10-CM: C61, Malignant neoplasm of prostate). Or if your oncologist only noted signs and symptoms, you should report that condition with 788.64 (Urinary hesitancy; ICD-10-CM: R39.11, Hesitancy of micturition).

According to the LCDs and the NCD, Medicare considers many ICD-9-CM codes indicating urological signs or symptoms — such as 599.71 (Gross hematuria; ICD-10-CM: R31.0, Gross hematuria), 599.72 (Microscopic hematuria, ICD-10-CM: R31.1, Benign essential microscopic hematuria), 788.41 (Urinary frequency; ICD-10-CM: R35.0, Frequency of micturition), or 788.43 (Nocturia; ICD-10-CM: R35.1, Nocturia) — as payable diagnoses for PSA determinations.

Check with your payer: The covered diagnoses for a PSA test vary from payer to payer. Each payer will have a list of acceptable covered diagnoses. If you bill any code within this list, you should not face denials. Regardless of the payer’s coverage determinations, you need to be sure you have documentation to support your diagnosis choice. 

Watch Out For Annual Coding Limits

Medicare only pays for one screening PSA per year. However, Medicare (and other payers) may reimburse you for as many diagnostic PSAs per year the patient needs, as long as you have a payable diagnosis.

Watch out: Make sure you are not only checking your own practice medical record. You should check to see if the patient has had a PSA screening at another office within the last year. You may occasionally find patients that have had a PSA performed at another doctor’s office, such as with their primary care doctor. If you then bill a screening PSA, the payer will deny your claim.

Self-pay option: If the patient wants or needs a screening PSA test before the one-year time limit is up, your best bet is to have the patient sign an advance beneficiary notice (ABN) agreeing to pay for the test himself if the payer refuses to reimburse for the earlier than usual PSA.