Pathology/Lab Coding Alert

Question: Why doesn't Medicare cover a prostate specific antigen (PSA) test for my patients with benign prostatic hypertrophy (BPH)?


New York Subscriber
 

Answer: Medicare does not include BPH (600.00, Hypertrophy [benign] of prostate without urinary obstruction) on its list of ICD-9 codes covered for a diagnostic PSA (84153, Prostate specific antigen  [PSA]; total).

-If the patient has symptoms of prostate carcinoma along with the BPH, such as hematuria, nocturia, urinary frequency and slow stream, a diagnostic PSA can be covered,- states CMS in Transmittal 234.

Medicare does cover an annual screening PSA testing for men over 50. Be careful that you-re not coding a diagnostic PSA when you should actually be reporting a screening PSA.

Key: Report annual PSA screenings with G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total), not 84153. Make sure to link G0103 to V76.44 (Special screening for malignant neoplasms; other sites; prostate), regardless of whether the patient has BPH.

Stay tuned: In a recent decision memo, CMS announced its intention to add 600.00 to its list of covered diagnoses for a PSA test. You can read the memo at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=183.