Urology Coding Alert

Let your diagnosis code choice support your claim.

While prostate specific antigen (PSA) tests may be commonplace in your urology practice, having more than one code to choose from can make the coding less than routine. Your diagnosis coding is just as important to your claim’s success as the test code. Read on to be sure you know the ins and outs of PSA coding to keep your claims from coming back unpaid. 

Check For Test Reason

You have two procedure codes to choose from for a PSA test, and which you choose will depend on the reason your urologist ordered the test. 

You should report a screening PSA for a Medicare beneficiary using G0103 (Prostate cancer screening; prostate specific antigen test [PSA]), says Elizabeth Hollingshead, CPC, CUC, CMC, CMSCS, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio. Some other payers follow these same guidelines.

On the other hand, for a diagnostic PSA test, you report 84153 (Prostate specific antigen [PSA]; total), says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

Consulting your urologist’s documentation is the only way you’ll know whether to code a screening or a diagnostic prostate specific antigen (PSA) test. “To be eligible for a screening PSA, they can never have had a prostate cancer diagnosis and they have to wait 365 days between draws,” Hollingshead explains. “If it’s a diagnostic PSA, there is a wide range diagnoses you can use and there is no time restriction on how often they have it done as long as it’s medically necessary.”

Match Diagnosis to Reason

For a screening test for a patient with no signs or symptoms of disease, you should use diagnosis code V76.44 (Special screening for malignant neoplasms; other sites; prostate) as the reason for the test. With ICD-10, you’ll report Z12.5 ( Encounter for screening for malignant neoplasm of prostate).

If you report another diagnosis code with the G0103, Medicare will not pay for it. You must use a screening diagnosis with a screening CPT® code. “In my experience, V76.44 is the only code Medicare will allow for a screening PSA,” Hollingshead confirms. “If the physician suspects something else, you might need to look at using a diagnostic PSA.”

Official word: CMS’s Medicare Claims Processing Manual, Chapter 18 - Preventive and Screening Services, (which can be found online at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf) guides you on this requirement: “Prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using screening (‘V’) code V76.44.”

When the urologist orders a diagnostic PSA test, and the documentation specifies that the test result shows an elevated PSA, you should report 790.93 (Elevated prostate specific antigen [PSA]) as the diagnosis. When ICD-10 comes around, you’ll use R97.2 (Elevated prostate specific antigen [PSA]).

If the test results are normal, however, you may report one of the following benign prostatic hyperplasia (BPH) codes:

• 600.00 — Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) [ICD-10: N40.0, Enlarged prostate without lower urinary tract symptoms]
  
• 600.01 — Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) [ICD-10: N40.1, Enlarged prostate with lower urinary tract symptoms].
  

Alternative: If the ordering physician documents a more specific diagnosis, such as prostate cancer, you should report the appropriate code (185, Malignant neoplasm of prostate; ICD-10: C61, Malignant neoplasm of prostate). Or if the urologist only noted signs and symptoms, you should report that condition with 788.64 (Urinary hesitancy; ICD-10: R39.11, Hesitancy of micturition), Ferragamo says. According to recent LCDs, Medicare considers many ICD-9 codes indicating urological signs or symptoms — such as 599.71 (Gross hematuria; ICD-10: R31.0, Gross hematuria), 599.72 (Microscopic hematuria, ICD-10: R31.1, Benign essential microscopic hematuria), 788.41 (Urinary frequency; ICD-10: R35.0, Frequency of micturition), or 788.43 (Nocturia; ICD-10: R35.1, Nocturia) — as payable diagnoses for PSA determinations.

Check with your payer: The covered diagnoses for a PSA test vary from payer to payer. Each payer will have a list of acceptable covered diagnoses. If you bill any code within this list, you should not face denials. Regardless of the payer’s coverage determinations, you need to be sure that you have documentation to support your diagnosis choice. 

Watch Out For Annual Coding Limits

Medicare only pays for one screening PSA per year. But Medicare (and other payers) may reimburse you for as many diagnostic PSAs per year the patient needs, as long as you have a payable diagnosis.

Watch out: Make sure you are not only checking your own practice medical record. You should check to see if the patient has had a PSA screening at another office within the last year. You may occasionally find patients that have had a PSA done at another doctor’s office, such as with their primary care doctor. If you then bill a screening PSA, the payer will deny your claim.

Self-pay option: If the patient wants or needs a screening PSA test before the one-year time limit is up, your best bet is to have the patient sign an advance beneficiary notice (ABN) agreeing to pay for the test himself if the payer refuses to reimburse for the earlier than usual PSA, Ferragamo says.