Pathology/Lab Coding Alert

Question: Our lab performs PSA screening tests. I'm familiar with the lab NCD for PSA, and I'm confused because it does not list as a payable diagnosis the code that the ordering physicians always give us, V76.44 . When we report the PSA test (84153) to Medicare with V76.44, we don't get paid.

Idaho Subscriber

Answer: Medicare's laboratory National Coverage Determination (NCD) for prostate specific antigen (PSA) testing does not apply to screening PSA tests. The NCD is for diagnostic PSA test 84153 (Prostate specific antigen; total), ordered based on signs and symptoms of disease. That's why the list of covered diagnosis codes includes conditions such as 185 (Malignant neoplasm of prostate), V10.46 (Personal history of malignant neoplasm; prostate) or symptoms such as 788.21 (Incomplete bladder emptying) or 788.43 (Nocturia).
 
A screening PSA is another matter. Medicare covers annual PSA screening tests that the physician orders in the absence of signs or symptoms of disease for men aged 50 years or older. Physicians are correct to order the screening PSA with code V76.44 (Special screening for malignant neoplasms; prostate).
 
But you're right, Medicare won't pay for 84153 if the physician orders it with diagnosis code V76.44. That's because Medicare requires labs to report screening PSA tests with G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total).
 
In a recent program memorandum on the subject of PSA coding (AB-03-132), Medicare had another reminder for providers: "Physicians or their staff who draw specimens for testing must report the date of collection of the specimen on orders for laboratory tests." In other words, as a laboratory, you have to report the correct diagnosis code and the correct date of service (specimen collection date) to Medicare, but you have to get that information from the ordering physician.