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Wiki G0103 Problems

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OMCMANAGER

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Vermillion, SD
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Used Z12.5 and G0103 for prostate screening. Denied. Any suggestions?
 
Who is the payer and what does the denial say?

It should be covered by Medicare for male patients over 50 years of age once per year. If you're dealing with a different payer, though, the coverage guidelines might not be the same.
 
There are special guidelines for age and frequency. We have been getting denials from payers with Z12.5, even for patients that meet the criteria. I'm not able to figure out why. Or if there's a different cpt code instead of HCPCS to use that is still a screening and not diagnostic... Denials have been from Medicare, Medi-Cal, Blue Cross, etc.
 
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