Question BCBS, Screening PSA (G0103) denials

cworrells

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Question...Is anyone else having issues with BCBS denying PSA screenings with the following codes, G0103/Z12.5? As far as all of my research goes, both of these codes are current and billable. BCBS denial states Dx issue. What am I missing? We have hundreds of claims with the same issue. All of the claim are for screening PSA's for male pt's who are 50 and over. Is there another Dx that I am missing? Please advise.
 

AaPe12

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Not sure but-are these BCBS commercial claims (meaning, not a Medicare BCBS plan)? They may want a CPT instead of a HCPCS code. Just my first thought.
 

TThivierge

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Question...Is anyone else having issues with BCBS denying PSA screenings with the following codes, G0103/Z12.5? As far as all of my research goes, both of these codes are current and billable. BCBS denial states Dx issue. What am I missing? We have hundreds of claims with the same issue. All of the claim are for screening PSA's for male pt's who are 50 and over. Is there another Dx that I am missing? Please advise.
Hi There,
I do a lot of lab coding. The PSA lab test needs to linked first with a definitive dx code such as N42.9, Disorders of the Prostate, or dx blocks of N40 or E29 or N52 per pt. documented problem from the doctor s notations or assessment. Or perhaps with the provider supported documentation requiring dx blocks of N48,N52, N40, E29 Etc.. Physicians are to list the reason why they order the lab test , but I think some of the doctors feel if the lab test definition is telling you what they are searching for till results come back to see more inflammatory problem. So PSA lab test using terms prostate is letting you know this is the area (unspecf dx of this prostate category to use this dx code. I always use N42.9 linked with the lab PSA unless doc notes tells me something differ from his assessment. I'd use a Z code last(Z13.89, Z12.5, Z11.3 ) and one of the N42 or other definitive dx code from doctor as first dx code to link to the PSA lab. UNLESS it is a first listed Z dx code according to what doc is searching .As example dx Z01 block maybe the doc does PSA lab for part of annual physical on men. Also check the protocol for your office too. That G code is to be billed only for Medicare payers, I hope doc selects PSA lab CPT of 84153, 84152, or 87426. sometimes per doc will use PSA lab for checking for STD look at dx blocks A52-A65 and link Z11.3 Or doc checking if the pt. has urinary problems or prostate cancer by the PSA lab.

I hope I have helped you.:)
(y):cool: Lady T
 
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cworrells

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Not sure but-are these BCBS commercial claims (meaning, not a Medicare BCBS plan)? They may want a CPT instead of a HCPCS code. Just my first thought.
We have actually had all of the BCBS (commercial, MA plan and state plans) deny them. We have reached out to our BCBS rep who has opened a project on it in early November but haven’t heard anything since.
 

cworrells

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Hi There,
I do a lot of lab coding. The PSA lab test needs to linked first with a definitive dx code such as N42.9, Disorders of the Prostate, or dx blocks of N40 or E29 or N52 per pt. documented problem from the doctor s notations or assessment. Or perhaps with the provider supported documentation requiring dx blocks of N48,N52, N40, E29 Etc.. Physicians are to list the reason why they order the lab test , but I think some of the doctors feel if the lab test definition is telling you what they are searching for till results come back to see more inflammatory problem. So PSA lab test using terms prostate is letting you know this is the area (unspecf dx of this prostate category to use this dx code. I always use N42.9 linked with the lab PSA unless doc notes tells me something differ from his assessment. I'd use a Z code last(Z13.89, Z12.5, Z11.3 ) and one of the N42 or other definitive dx code from doctor as first dx code to link to the PSA lab. UNLESS it is a first listed Z dx code according to what doc is searching .As example dx Z01 block maybe the doc does PSA lab for part of annual physical on men. Also check the protocol for your office too. That G code is to be billed only for Medicare payers, I hope doc selects PSA lab CPT of 84153, 84152, or 87426. sometime spur doc willuse PSA lab for checking for STD look at dx blocks A52-A65 and link Z11.3

I hope I have helped you.:)
(y):cool: Lady T
All of these that are denials are from APE labs, so the screening PSA which is why we use the encounter for screening code, Z12.5. Our recalls for diagnostic PSA’s are paid using one of the DX codes not the screening code. They have always paid this same lab and Dx code combo, and all of our other payers still pay it with no issues. I’m convinced it’s is a glitch on the BCBS side.
 

TThivierge

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All of these that are denials are from APE labs, so the screening PSA which is why we use the encounter for screening code, Z12.5. Our recalls for diagnostic PSA’s are paid using one of the DX codes not the screening code. They have always paid this same lab and Dx code combo, and all of our other payers still pay it with no issues. I’m convinced it’s is a glitch on the BCBS side.
Yes Z code can be denied if first listed dx code on the claim.. There are different reasons for Z dxcodes. However definitive dx codes first on claim, then Z encounter code is way to bill that PSA lab. Yes it sounds like whoever is handling the BC/BS lab is uninformed. Id refer them to the NCCI CMS website by using that lab code in your appeal letter. The insurance company reps sometimes get confused.
Have a great day!
Lady T:giggle:
 

Smossburg

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Marietta, Georgia
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Hi There,
I do a lot of lab coding. The PSA lab test needs to linked first with a definitive dx code such as N42.9, Disorders of the Prostate, or dx blocks of N40 or E29 or N52 per pt. documented problem from the doctor s notations or assessment. Or perhaps with the provider supported documentation requiring dx blocks of N48,N52, N40, E29 Etc.. Physicians are to list the reason why they order the lab test , but I think some of the doctors feel if the lab test definition is telling you what they are searching for till results come back to see more inflammatory problem. So PSA lab test using terms prostate is letting you know this is the area (unspecf dx of this prostate category to use this dx code. I always use N42.9 linked with the lab PSA unless doc notes tells me something differ from his assessment. I'd use a Z code last(Z13.89, Z12.5, Z11.3 ) and one of the N42 or other definitive dx code from doctor as first dx code to link to the PSA lab. UNLESS it is a first listed Z dx code according to what doc is searching .As example dx Z01 block maybe the doc does PSA lab for part of annual physical on men. Also check the protocol for your office too. That G code is to be billed only for Medicare payers, I hope doc selects PSA lab CPT of 84153, 84152, or 87426. sometimes per doc will use PSA lab for checking for STD look at dx blocks A52-A65 and link Z11.3 Or doc checking if the pt. has urinary problems or prostate cancer by the PSA lab.

I hope I have helped you.:)
(y):cool: Lady T
I am a medical biller for a doctor's office, we bill medicare for G0103 as a screening for prostate cancer and it keeps getting denied. We bill it with an annual exam. Our patient's don't have a dx code is some cases because this is a screening. What can I do?
 

njycarter17

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Vine Grove, KY
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Question...Is anyone else having issues with BCBS denying PSA screenings with the following codes, G0103/Z12.5? As far as all of my research goes, both of these codes are current and billable. BCBS denial states Dx issue. What am I missing? We have hundreds of claims with the same issue. All of the claim are for screening PSA's for male pt's who are 50 and over. Is there another Dx that I am missing? Please advise.
We have tried to bill G0103 with dx Z12.5 and they deny because they consider it bundled when performed during Annual Physical Exam same DOS.
 
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