Oncology & Hematology Coding Alert

Here’s how to understand the differences between these four prostate cancer tests.

On the surface, little differentiates G0103 (Prostate cancer screening; prostate specific antigen test [PSA]) from 84152 (Prostate specific antigen (PSA); complexed (direct measurement)), 84153 (... total), and 84154 (... free). However, each one of these prostate specific antigen (PSA) tests serves a different purpose, which means you must match them up with the correct diagnosis code to receive reimbursement and avoid denials.

To do that, you’ll have to know whether the patient has received a definitive prostate cancer diagnosis, the patient is in remission from prostate cancer, or the patient is free of any sign or symptom of “the most common cancer in American men,” according to the American Cancer Society (Source: www.cancer.org/cancer/prostate-cancer/about/key-statistics.html).

Here, then, are all the codes you need to know.

When Do I Use G0103?

As the descriptor for G0103 clearly states, you should only use the code for PSA screening.

What that means: You should only use G0103 for a patient who has never received a prostate cancer diagnosis and who is not showing any signs or symptoms such as an enlarged prostate (which your provider may refer to as benign prostatic hyperplasia, or BPH), elevated PSA levels, or other symptoms or signs that may point toward prostate cancer.

To use the code correctly, you will need to check the provider’s notes to make sure the patient does not exhibit any of these prostate or other urological conditions. If the oncologist doesn’t document any, but does indicate he is ordering the test as a screening, link ICD-10-CM diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate) to G0103.

Remember: Medicare will pay for an annual PSA screening test providing you report Z12.5 alone to support the lab order. If you do report another diagnosis code with the G0103, Medicare and payers following Medicare rules may deny it. You must always go by what the oncologist documents, not by what gets paid.

When Should I Use 84152-84154?

As 84152-84154 are not screening codes, you will use them whenever your provider orders a diagnostic PSA test. This means your provider’s notes will need to support medical necessity for the test. So, “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, Associate Partner, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

The most recent edition of the Medicare National Coverage Determinations (NCD) Coding Policy Manual elaborates that PSA tests, “when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer. PSA also serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment” (Source: Oct. 2021 NCD Coding Policy Manual, p. 2205-2207, found at >www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=152&ncdver=1).

The NCD goes on to list numerous ICD-10-CM codes you can use to link with 84153, including, but not limited to, such definitive diagnoses as:

• C61 (Malignant neoplasm of prostate)
• D07.5 (Carcinoma in situ of prostate)
• D40.0 (Neoplasm of uncertain behavior of prostate)
• N40.0 (Benign prostatic hyperplasia without lower urinary tract symptoms)
• N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms)
• Z85.46 (Personal history of malignant neoplasm of prostate)

along with such urological signs or symptoms as:

• R31.0 (Gross hematuria)
• R31.1 (Benign essential microscopic hematuria)
• R35.0 (Frequency of micturition)
• R35.1 (Nocturia)
• R39.11 (Hesitancy of micturition)
• R97.20 (Elevated prostate specific antigen (PSA))
• R97.21 (Rising PSA following treatment for malignant neoplasm of prostate)

And don’t forget this: If your provider orders a diagnostic PSA test for a patient who has successfully undergone treatment for prostate cancer, and whose cancer is now in remission, you should not use the C61 diagnosis. Instead, you should report Z85.46.

What Is the Difference Between 84152-84154?

Most of the time, you’ll code 84153 when your provider orders a diagnostic PSA. This is the most common of the three tests because it evaluates a patient’s total PSA level.

The other tests evaluate PSA fractions instead. Of them, 84154, the so-called free test, measures “the ratio of how much PSA circulates free [unattached to blood proteins] compared to the total PSA level. The percentage of free PSA is lower in men who have prostate cancer than in men who do not,” according to the American Cancer Society. A free test “might be used to help decide if you should have a prostate biopsy” when a “total PSA test result is in the borderline range” (Source: www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/tests.html).

The complexed test — reported with 84152 — “directly measures the amount of PSA that is attached to other proteins (the portion of PSA that is not “free”). This test could be done instead of checking the total and free PSA, and it could give the same amount of information, but it is not widely used,” the American Cancer Society adds.