Urology Coding Alert

When a urologist performs a prostate specific antigen (PSA) test in the presence of signs or symptoms of prostate cancer, the diagnosis code determines whether you will be reimbursed. HCFA has no national policy for coverage of nonroutine PSA testing, so each carrier has its own local medical review policy (LMRP) indicating what diagnosis codes justify medical necessity for 84154 (prostate specific antigen [PSA]; free) and CPT 84153 (prostate specific antigen [PSA]; total).

Some carriers have LMRPs only for 84153, which is covered by more diagnosis codes than 84154. Policies that refer to both PSA testing codes, however, do not distinguish between diagnosis codes by CPT code, but have overall medical necessity lists for both 84153 and 84154. Some carriers do not reimburse total and free PSA tests on the same day.

Distinguish Between 84153 and 84154

Free PSA (84154) helps discover borderline elevations of total PSA (84153). Free PSA may be done after a total PSA to find out if there is a borderline elevation. Total PSA lacks the specificity needed to determine whether the condition is benign or cancerous. Both tests together provide a ratio of free/total PSA, which when used with the total PSA gives the urologist a more direct indication of the presence of prostate cancer compared to benign enlargement, also known as benign prostatic hyperplasia (BPH).

Total PSA is the more commonly performed test. It can indicate the possible presence of prostate cancer in, for example, a patient with BPH. Total PSA can also follow the progress of a prostate tumor once diagnosed and follow prostate cancer patients who have had treatment but must be monitored to detect metastatic or persistent disease.

BPH Diagnosis May Cause Denials

BPH is the main diagnosis urologists use when performing screening PSA tests, explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stonybrook. Significantly, many carriers wont pay for BPH diagnosis codes. Many urologists order PSA testing for the diagnoses in the 600 series, some of which are covered by some carriers, such as 600.x (hyperplasia of prostate), 601.x (inflammatory diseases of prostate) and 602.x (other disorders of prostate). But when a urologist uses one of the 600 series of prostate hyperplasia diagnosis codes, the payer may deny the claim. Some carriers do not cover 84153, the procedure used for the screening PSA, with any of these diagnosis codes.

It varies not only from carrier to carrier but for different areas within a carrier system, Ferragamo notes. Check with your carrier for covered diagnosis codes.

For example, New York Medicare covers for both 84153 and 84154: 170.2, 185, 188.5, 188.8, 196.5, 196.6, 196.8, 198.5, 198.82, 233.4, 236.5, 239.5, 790.93, V10.46 and V71.1. These are all current cancer diagnosis codes except for 790.93 (elevated PSA), V10.46 (personal history of malignant neoplasm; prostate) and V71.1 (observation for suspected malignant neoplasm). The absence of the BPH diagnosis codes is striking, but not unusual.

The Georgia Medicare carriers LMRP covering 84154 states that the only payable diagnosis is 790.93 (other nonspecific findings on examination of blood; elevated prostate specific antigen, [PSA]). Free PSA is not covered if there is already a diagnosis of prostate cancer. Noridian of Colorado also has a policy for 84154 alone, and, like the southern carrier, the only covered code is 790.93.

Urology practices should maintain current LMRPs or bulletins regarding PSA testing in their billing files and check with these before filing claims to help avoid denials and misfiling of claims.

Tip: In addition to using the correct diagnosis, you must add the extra digits. Failing to do so results in denials for truncated diagnosis codes.

Code V10.46 for Recalls

For PSA rechecks in patients with diagnosed and treated prostate cancer, use V10.46. For example, after treating a patient for prostate cancer by total removal of the prostate (radical prostatectomy), the urologist checks the PSA to detect recurrence of the disease. The coder cant use prostate cancer as the diagnosis because the patient no longer has prostate cancer. But you can use personal history of prostate cancer (V10.46).

PSA tests are also performed on patients with other kinds of cancer. Patients with bladder cancer who had the tumor removed and therefore no longer have bladder cancer are one case in point. You cant use a cancer code, because the person doesnt have cancer anymore, says Jackie Shovan, CPC, financial counselor for the division of urology at the University of Utah in Salt Lake City. Its important to do the test because sometimes the cancer starts in the prostate and metastasizes to the bladder. Use V10.51 (personal history of malignant neoplasm; bladder).

Regardless of what diagnosis code gets the claim paid, use the diagnosis code that applies to the particular circumstances. As one LMRP says, It is not enough to link the procedure code to a correct, payable ICD-9 code. The diagnosis or clinical suspicion must be present for the procedure to be paid. You need to document all conditions and diagnoses with relevant signs and/or symptoms and laboratory test results. The treating urologist must document an order for each test.

Note: Some carrier LMRPs say not to use V82.9 (special screening for other conditions, unspecified condition) because this will result in a denial of claims for noncovered screening services.

When to Use a Waiver

PSA testing presents many examples of situations in which a physician orders a procedure (the test) but does not get paid for it at least not by a particular carrier. Thats why a physician should get a waiver before doing the test, says Donna Cardarelli, biller for Urology Associates, a four-urologist practice in Haverhill, Mass.

Commercial payers are much more lenient than many Medicare carriers when it comes to paying for PSA testing. But even so, do not use 600.9 (hyperplasia of prostate, unspecified), Cardarelli urges. Its an unspecified code, and you shouldnt use it theres always a more appropriate one, she says. We stick to the Medicare list for all patients. However, Cardarelli adds that many HMOs require their patients to go to a primary care physician (PCP) for PSAs.

Use V76.44 for Screening

If you are screening a patient for prostate cancer a routine test done in the absence of any signs or symptoms use G0103 (prostate cancer screening; prostate specific antigen test [PSA], total) for Medicare patients and 84153 for commercial patients. Use diagnosis code V76.44 (special screening for malignant neoplasms; prostate) for both.

Code 84152 Not in LMRPs

A new CPT code as of 2001 for complexed PSA 84152 (prostate specific antigen; complexed) has yet to make it into LMRPs. It can be difficult to find a lab with the equipment to run this test. According to some pathologists, because its more direct, the complexed test is more accurate than the number derived from the ratio of free-to-total PSA. For more information on this test, see New Code Provides More Accurate Billing for PSA Test on page 4 of the January 2001 Urology Coding Alert.