Distinguish Screening From Diagnostic Testing to Avoid PSA Coding Errors
Remember: It all starts with the reason for the test. Although prostate-specific antigen (PSA) testing is one of the most common cancer screening services for older men, it continues to cause confusion for coders, especially when the time comes to determine whether a test was a preventive screening service or a diagnostic evaluation. That distinction has significant implications: While screening PSA tests may qualify for preventive coverage benefits under Medicare and many commercial plans, diagnostic PSA tests require documentation of signs, symptoms, abnormal findings, or history that establishes medical necessity. To accurately code PSA testing, coders must understand when to apply Z12.5 (Encounter for screening for malignant neoplasm of prostate) versus when to report a diagnosis code that reflects a clinical finding, such as R97.20 (Elevated prostate specific antigen [PSA]). Further, coders should know how to handle situations where a screening test yields an abnormal finding and subsequent tests transition from preventive screening to diagnostic evaluation. Review these tips for distinguishing screening from diagnostic PSA testing and selecting the appropriate codes. Start With the Reason for the Test To support early detection, clinicians perform screening tests in asymptomatic patients who have no signs or symptoms of disease. Diagnostic PSA testing, meanwhile, evaluates a known clinical concern. In screening testing, a patient who does not have any documented urinary issues, prior abnormal PSA findings, or a history of prostate cancer that requires surveillance undergoes routine prostate cancer screening. Assign Z12.5 to report these screenings. Phrases such as “routine prostate cancer screening,” “annual PSA screening,” or “screening laboratory studies” support selection of Z12.5 because they indicate that the urologist performed the PSA test as a screening service. Now, let’s discuss diagnostic testing in more detail. If a physician investigates symptoms, monitors an abnormal PSA result, or treats a patient with a history of prostate disease or cancer, the examination becomes a diagnostic test. For example, a patient who presents with urinary hesitancy may undergo PSA testing as part of a diagnostic workup. You’ll assign the diagnosis code that reflects the documented symptom or abnormal finding rather than Z12.5. In this example, you would report R39.11 (Hesitancy of micturition). However, if the physician documents a more definitive diagnosis, such as N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms), code the confirmed condition rather than the symptom code. Know the Procedure Codes PSA testing uses different procedure codes depending on whether the service is a screening test or a diagnostic test. For a Medicare-covered prostate cancer screening, report HCPCS Level II code G0103 (Prostate cancer screening; prostate specific antigen test (PSA)). When the physician orders PSA testing to evaluate a symptom, abnormal finding, or known condition, report CPT® code 84153 (Prostate specific antigen (PSA); total). Because payers often apply different coverage rules to screening and diagnostic testing, verify both the diagnosis code and the procedure code before submitting the claim. Understand When an Elevated PSA Changes the Coding Consider the following scenario: A 68-year-old patient presents for an annual wellness visit. They report no urinary symptoms, and the physician orders a routine PSA screening. The coder reports Z12.5, which accurately reflects the purpose of the test at the time it was ordered. But one week later, the PSA test returns with elevated results. The physician asks the patient to return in three months for a repeat PSA test. The reason for the repeat PSA evaluation changes at this point is because the physician now evaluates an abnormal finding rather than performing a routine screening. Therefore, the coder should use R97.20 to report the follow-up PSA test. Once an abnormal result exists and becomes the reason for further testing, avoid continuing to assign Z12.5 to all subsequent PSA tests after an initial screening encounter. Don't Let the Visit Type Drive the Coding Do not assume that every PSA ordered during a preventive or annual wellness visit automatically qualifies as a screening service. Let’s say that a patient presents for an annual preventive examination and reports worsening urinary frequency and a weak urinary stream. The physician orders a PSA test as part of the evaluation. Although the encounter includes preventive services, the provider ordered the PSA test to investigate the patient’s symptoms. The diagnosis coding should reflect the symptoms or condition under evaluation rather than Z12.5. Similarly, a urologist may order PSA testing during a routine follow-up appointment for a patient with a history of elevated PSA levels. Even if the patient has no current symptoms, the test monitors a previous abnormal finding. As a result, you should report the documented finding rather than a screening code. Consider Medicare Frequency Limitations As a urology coder, you must understand the difference between screening and diagnostic PSA testing in every scenario, but Medicare frequency limitations pose an extra challenge. Medicare Part B covers one screening PSA blood test every 12 months for eligible beneficiaries, but coders may encounter challenges when a physician orders a second PSA test before the beneficiary qualifies for another covered screening service. For example, suppose a patient receives a screening PSA in January and the result is elevated, so their physician orders repeat testing in July. Because the physician ordered the July test to evaluate an abnormal finding rather than perform another screening service, you should report the test as diagnostic with R97.20. If coders fail to recognize this transition from screening to diagnostic testing, payers may deny the claim based on screening frequency limitations even though the service meets the requirements for a medically necessary diagnostic test. To code PSA testing correctly, follow these steps: Michelle Falci, BA, M Falci Communications LLC
