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Urology Coding Alert

Reader Questions:

Include Prostate Massage With E/M

Published on Fri Mar 06, 2009

Question: My doctor is doing a test called PSA3. We are considering doing this in our facility. However, along with this test, a prostatic massage is required. Is there a code for this, or is it included with the E/M service? California Subscriber Answer: You should include the prostatic massage within the E/M service you report. This will not be a separately reportable service. However, if the urologist does a microscopic examination of the prostatic secretions (known as a wet smear), you should bill for that service using 87210 (Smear, primary source with interpretation; wet mount for infectious agents [e.g., saline, India ink, KOH preps]). Note: You'll need to append modifier QW (CLIA waved test). To use this modifier, your physician must have a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA). Don't forget: In addition to appending modifier QW, be sure to write your CLIA waiver number [...]
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