Urology Coding Alert

Before you bill your next PSA screening, you'd better get cozy with the new clinical diagnostic laboratory coding guidelines or chances are your claim will be denied for lack of established medical necessity. CMS' new national coverage determination (NCD) for prostate specific antigen screenings becomes effective Nov. 25, 2002, and the outlined covered diagnosis codes may surprise you. CMS has given carriers until Jan. 1, 2003, to begin editing for these changes. The NCD guidelines which have a mandated adoption policy for all Medicare carriers for diagnosis coding PSA add a new twist to correct coding practice: The covered diagnosis codes vary depending on whether the patient has symptoms of benign prostate hyperplasia before a PSA is administered. Let's say a patient presents with urinary retention or nocturia secondary to a suspected prostate disorder. In this case, you are required to record diagnosis codes reflecting these symptoms using icd-9 788.20 and ICD9 788.43. But if a patient presents for an annual checkup and a PSA is obtained as a preventive or screening measure the patient has no urinary symptoms or prostatic findings don't expect reimbursement without an acceptable V code.

"This will be huge," says Morgan Hause, CCS, CCS-P, privacy and compliance officer with Urology of Indiana. "Most urology groups will need to re-educate staff on the new requirements" for reporting 84153 (Prostate specific antigen [PSA]; total) for Medicare patients. Tailor Your PSA Coding to Symptoms Present Physicians use PSA tests to detect residual cancer post-prostate cancer removal, i.e., radical prostatectomy. The test can act as a "marker in following the progress of most prostate tumors once a diagnosis has been established," according to CMS, but it can also aid in the initial diagnosis of prostate cancer. PSA testing can even take diagnosing prostate cancer one step further and differentiate between benign and malignant tumors in men with signs of a potential prostate disorder, i.e., hematuria and other urinary tract symptoms. When a patient has possible symptoms of BPH, a PSA test is considered diagnostic. Code the condition to the highest degree of certainty, which may include reporting signs, symptoms, previous abnormal test results, and exposure to communicable disease, says Wendy Brady, CPC, coder and insurance clerk with Oconee Urology in Milledgeville, Ga.

Don't fall into the trap of using the diagnosis codes representing "suspected" or "probable" diagnoses, Brady advises. "There has to be some sign or symptom for the urologist to perform the [PSA] test," and you are required to document what led the physician to believe the patient has prostate cancer. Brady uses prostate nodules and previously elevated PSA levels as examples of symptoms motivating the urologist to order a PSA. The following list is a compilation of [...]