Pathology/Lab Coding Alert

Medicare began coverage for two procedures for prostate cancer screening on Jan. 1, 2000, in response to a mandate in the Balanced Budget Act of 1997. The procedures are a digital rectal exam and a laboratory blood test for PSA (prostate specific antigen). Obtaining reimbursement for these procedures requires an understanding of the difference between the level-two HCPCS and CPT codes for the tests, as well as understanding conditions of coverage.

New HCPCS Codes

The two new procedure/professional service HCPCS codes that are used to report screening for the early detection of prostate cancer are G0102 (prostate cancer screening; digital rectal examination) and G0103 (prostate cancer screening; prostate specific antigen test [PSA], total). Code G0103 is a lab test that identifies the level of an immunocytochemical marker for prostate cancer in the patients blood. G0102 involves a physical examination of the patients prostate for nodules or other abnormalities.

Subject to the restrictions laid out by the Health Care Financing Administration (HCFA), the advent of these codes means that Medicare patients who do not have symptoms or a diagnosis that supports prostate cancer tests can benefit from their use as an early-detection tool, according to Ken Wolfgang MT (ASCP), CPC, CPC-H. Wolfgang is president of Kenneth E. Wolfgang Inc. Health Services Consulting in Portland, Ore., a coding consultation company specializing in pathology. Healthcare providers should check with their other payers to determine their specific coverage policies for prostate cancer screening, he says. An appropriate ICD-9 code to identify the reason for the screening procedures would be V76.44 (special screening for malignant neoplasms, prostate).

Whether the patient comes in for a preventive medicine evaluation or presents with symptomatic complaints unrelated to prostate disease, code G0103 can be reported on the same day for the same patient as the appropriate evaluation and management (E/M) code, says Wolfgang. This code represents a screening laboratory procedure that is ordered by the patients physician or other approved healthcare provider.

On the other hand, code G0102 cannot be reported on the same day as an office visit in many cases. Doug Knapman, MBA, business manager of Professional Billing Systems Inc. of Michigan City, Ind., specializing in pathology and laboratory billing, points out that HCFA program memorandum B993760 states, A digital rectal exam that is provided on the same day as a covered E/M service is bundled into the payment for the E/M service.

Code G0102 represents an examination that should be included in the appropriate level problem-oriented E/M service. One of the three key components used to determine the service level of a problem-oriented E/M service is the extent of the examination performed, in terms of body systems involved. The digital rectal exam would be considered part of the physical examination, and taken into account in determining the correct E/M level.

On the other hand, if a patient comes for a prostate cancer screening only, with no complaints and not as part of a covered office visit, code G0102 should be reported. Knapman again refers to the HCFA directive, which states, If the digital rectal exam is the only service provided or is provided as part of an otherwise non-covered service, such as code 99397 (periodic preventive medicine reevaluation and management of an individual ; 65 years and over) for a preventive service visit, then code G0102 could be payable separately. Code G0103 would be reported as well, if the PSA screening lab test is ordered.

Coverage Requirements

HCFA has placed certain restrictions on reimbursement for these prostate cancer-screening tools.

Three requirements must be met:

1. Patient is a male, aged 50 or older;
2. Test/procedure is ordered/performed by a doctor of medicine or osteopathy, or a qualified physician assistant, nurse practitioner or clinical nurse specialist;
3. Test/procedure is performed at a frequency no greater than once every 12 months.

HCFA put edits in place that will result in reimbursement denial for patients who do not meet these age, sex and frequency guidelines. Note that although Medicare coverage for G0102 and G0103 was effective Jan. 1, 2000, the edits originally were scheduled to be operational with HCFAs quarterly release of the common working file (CWF) in April 2000. Due to a delay in the release of the CWF, that date was moved to May 2000. Carriers have been instructed not to reopen claims processed between Jan. 1, 2000, and the implementation date of the edits unless requested by the provider.

CPT Codes

According to Wolfgang, the CPT codes for PSA testing are to be used when the tests serve a diagnostic, rather than a screening, purpose. The codes are 84153 (prostate specific antigen [PSA]; total), and 84154 (prostate specific antigen [PSA]; free). The difference between the two codes is whether the test is measuring the level of total PSA in the blood or only that portion of PSA that is not bound to certain serum proteins.

The physician determines which test to administer, based on the medical needs of the patient, says Wolfgang. Either of these tests may be carried out for patients who returned a positive PSA screen, or who are being treated for prostate cancer (e.g., ICD-9 code 185) or benign prostatic hypertrophy (ICD-9 code 600). For example, he continues, The physician may order a code 84153 test to monitor a patient periodically, following surgery for prostate cancer. If the descending level of total PSA rebounds and begins to rise again, the physician may order 84154 to isolate the source of the increasing antigen levels.

Should PSA testing be reported using code 86316 (immunoassay for tumor antigen [e.g., cancer antigen 125], each), as was done commonly in the past? No, answers Wolfgang. Although 86316 accurately describes the type of testing involved in PSA, it is a less specific descriptor than codes 84153-84154, which were added to CPT within the last few years. Payers should be using the updated codes.

Conclusion

If physicians and laboratories want to be reimbursed for prostate cancer screening for Medicare patients, they need to be certain that screening is indicated clearly in the medical record and on the requisition form for the lab test, advises Wolfgang. If the physician does not indicate screening, and the laboratory uses 84153 rather than G0103 to report PSA, the likelihood of denial is high.