Wiki PSA Denials

Community Wiki

This is a community-maintained wiki post containing the most important information from this thread. You may edit the Wiki once you have been on AAPC for 30 days and have made 5 posts. Learn More
G
Code: R97.20

Code Name: ICD-10 Code for Elevated prostate specific antigen [PSA]

Block: Abnormal tumor markers (R97-R97.8)

Details: Elevated prostate specific antigen [PSA]

Guidelines: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Note: This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.
Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.
The conditions and signs or symptoms included in categories R00-R94 consist of:
(a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated;
(b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;
(c) provisional diagnosis in a patient who failed to return for further investigation or care;
(d) cases referred elsewhere for investigation or treatment before the diagnosis was made;
(e) cases in which a more precise diagnosis was not available for any other reason;
(f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.


Excludes 2: abnormal findings on antenatal screening of mother (O28.-)
certain conditions originating in the perinatal period (P04-P96)
signs and symptoms classified in the body system chapters
signs and symptoms of breast (N63, N64.5)

For more details on R97.20, ICD-10 Code for Elevated prostate specific antigen [PSA] , visit: https://coder.aapc.com/icd-10-codes/

TammyHF

Guru
Messages
170
Location
Wichita, KS
Best answers
0
Is anyone getting denial for PSA claim after 10/1/2016 for using the new ICD 10 code R97.20 Elevated prostate specific antigen [PSA]?
 

Coder2468

Guest
Messages
19
Best answers
0
Yes, I have. I received a Medicare denial just a few days ago for PSA 84153. Medicare denied for no medical necessity. I initiated a redetermination online and attached scanned documentation showing that R97.2 has been updated to R97.20. I have not received denials from any other payers - yet. Hopefully I don't!
 

MeriAnn

New
Messages
5
Location
Clearwater, FL
Best answers
0
Our office has received denials from Medicare. We found out that Medicare's lab system is not accepting the new DX codes until January 3, 2017. See their National Coverage Determination ID# 190.28.
 

KMCFADYEN

Expert
Messages
285
Location
Roanoke, VA
Best answers
0
This is a post from a previous thread by:
holloman@msaphy.com

Looks like the update to the NCD file will not occur until January or April 2017 per the CMS website. The new ICDs will be backdated to their effective date, 10/1/16, but they sure make it a pain in the mean time.

"Please note that due to this being the first regular ICD-10 code update since the partial code freeze October 1, 2011, (there were limited new codes introduced in fiscal years 2012, 2013, 2014, and 2015), and the voluminous number of new codes involved, the Medicare shared systems will split implementation of the new codes over the January 2017 and April 2017 quarterly updates. While the implementation dates will be in January and April, the effective dates of the new codes will still be October 1, 2016. All deleted codes will not be valid for payment after September 30, 2016. Contractors will be instructed to adjust claims brought to their attention."

https://www.cms.gov/Medicare/Coverag...NCDsICD10.html
 
Last edited:

Coder2468

Guest
Messages
19
Best answers
0
I had initiated a redetermination for the denied PSA charge, and I just received an answer today. Medicare is stating that their appeal decision is unfavorable, and they are maintaining that they denied it correctly. I just wanted to post this update so others don't waste their time doing appeals. Looks like we'll just have to wait until they do their update. It's very frustrating having these PSAs clogging up my AR!
 
Messages
1
Best answers
0
This is the posting from CMS...
2017 ICD-10 CM diagnosis codes are required on claims for services performed on or after 10/1/2016. Changes to the claims processing systems to implement the ICD-10 updates for CMS NCDs for laboratory services have been implemented as of 12/5/2016. Laboratory claims for dates of service on or after 10/1/2016 with ICD-10 diagnoses and ICD-10 procedure codes associated with NCD edits should now be processing normally. 12/16/2016: For laboratory based claims, a system resolution was installed on Monday, 12/5/2016. Providers are advised to resubmit all associated claims denied on or after 10/1/2016 for reprocessing. Providers are also advised to continue to monitor this Production Issue Alert and NGS listserv releases for any additional details or instructions.
 

misstigris

Networker
Messages
63
Best answers
0
Anyone have any more updates? We are getting our claims for Medicare paid now, but BlueCross Medadvantage and Healthnet Medadvantage are still denying and referring back to the NCD 190.31
 
Top