Finding the right code to report for a Prostate Specific Antigen (PSA) test can be a challenge. Your key to correct prostate specific antigen test coding lies in your capacity to distinguish a screening PSA test from a diagnostic PSA test. Here are some expert tips to ensure you are right on target as far as your PSA coding is concerned.
Set apart screening from diagnostic
Screening: Report a screening PSA for a Medicare beneficiary using G0103 (Prostrate cancer screening; prostrate specific antigen test. There are other payers who follow these same guidelines.
Elizabeth Hollingshead, CPC, CMC, corporate billing and coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio says, Medicare requires that all yearly screening PSAs be billed with G0103.
Diagnostic: According to Teresa A. Dailey, CPC, coding specialist for Urology Center of Spartanburg in South Carolina, the right code for a diagnostic PSA test is 84153.
“84153 is a diagnostic code, and would be used when there’s an established disease/illness process which is outlined in the Local Coverage Determinations for that CPT code,” says Dan Rogers, administrator for Biloxi Bay Urology Center PLLC and Gulf South Urology in Biloxi, Miss.
“I’d bill 84153 when a diagnostic PSA is required for another medically necessary reason; for instance, observation of a rising PSA or a confirmed diagnosis of prostrate cancer that requires the PSA be done after treatment has been started to assure its effectiveness,” says Hollingshead.
Be on the lookout for documentation clues: A coder can make out which code to report by looking at the patient’s diagnosis in the medical record, Laura Cwiklinski, office manager at Urology Partners Inc. in Cleveland says, but the physician shares the responsibility. “The medical coder should be able to make out the patient diagnosis within the physician notes. This’ll allow the coder to know what CPT code to use. It is the responsibility of the physician to be specific when drawing the patient’s diagnosis in the chart.
Use Dx to support your choice of code
When your urologist orders a screening PSA test for a patient with no signs or symptoms of disease, you should use diagnosis code V76.44 (Special screening for malignant neoplasms; other sites; prostate) as the reason for the test.
Cwiklinski says, “If you code another diagnostic diagnosis with the G0103, Medicare won’t pay for it.” “You must make use of a screening CPT (code) with a screening ICD-9.”
Official word: CMS’s The Guide to Medicare Preventive Services manual (you can find it online at (www.cms.hhs.gov/mlnproducts/downloads/psguid .pdf) talks about this requirement:
“There’re no specific diagnosis requirements for prostrate screening tests and procedures. But if screening is the reason for the test and/or procedure, the appropriate screening (“V”) diagnosis code must be chosen while billing Medicare. The screening diagnosis code of V76.44 (special screening for malignant neoplasms, prostrate) is reported.”
Hopeful tidings: Roger says, “According to some newer LCDs, you would get paid with another diagnosis with the G0103,” adding, “I’d still continue to use the V76.44 if appropriate.” But Roger explains that the new coverage determinations allow you to code PSA screenings with diagnoses like benign prostatic hyperplasia (BPH, 600.00 or 600.01) and others.
Verify with your payer: Cwiklinski cautions, the covered diagnosis for PSA test vary from payer to payer. Each payer will have a list of acceptable, covered diagnosis. “You’ll not have any denials if you bill within these codes list,” she adds. Irrespective of the payer’s coverage determinations, Hollingshead stresses, “you need to be sure you have documentation to support your diagnosis choice.”
Diagnosis elevated PSA: When the urologist orders a diagnostic PSA test and the documentation specifies that the test result shows an elevated PSA, you should go for 790.93 (Elevated prostate specific antigen [PSA} as the diagnosis.
If the results come out to be normal, you would report the BPH as the reason for the test. As you must report the BPH code to the fifth digit, you will have to know whether the patient has a urinary obstruction or is symptomatic so you can choose the right code as follows:
600.00 – Hypertrophy (benign) of prostate minus urinary obstruction and other lower urinary tract symptoms (LUTS). 600.01 – Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms. Option: If the ordering physician documents a more specific diagnosis, like prostate cancer, you should report the appropriate code (185, malignant neoplasm of prostate). Or if the physician only noted signs and symptoms, you should that condition, such as 788.64 (urinary hesitancy). If we go by recent LCDs, Medicare considers many ICD-9 codes indicating urological signs or symptoms like 599.71 (Gross hematuria), 599.72 (Microscopic hematuria), 788.41 (Urinary frequency), or 788.43 (Nocturia) — as payable diagnoses for PSA determinations. Follow once-a-year coding limits Gaye Pratt, coder/biller for Dr. Vincent P. Miraglia in Stuart, Fla. says, “Medicare only pays for one screening PSA per year.” However, Medicare (as well as other payers) may reimburse you for as many diagnostic PSAs per year as the patient requires, as long as you have a payable diagnosis, adds Pratt. Hollingshead says, “In my opinion, the biggest pitfall for screening PSAs is the timing.” It’s covered only once every 12 months for Medicare, with most commercial payers following closely. You need to ensure that you have at least 366 days (367 for leap years) between screening PSAs,” she confirms. Watch out: See to it you are not just checking the medical record of your practice. You should check to see if the patient has had a screening at another office within the past one year. “On occasion, we have had patients that have had a PSA done at another doctor’s office like the primary care doctor, then we draw a screening PSA and Medicare denies it owing to the fact that it will pay only for one screening PSA a year,” cautions Dailey. Self-pay option: If the patient requires a screening PSA test before the one-year time limit is up, your best option is to have the patient sign an ABB agreeing to pay for the test himself. Roger says, “Typically, you cannot make use of a ‘blanket’ ABN; however, you may be able to have the patients sign one stating that if they had the test done elsewhere within the allowed timeline, they’ll be responsible for payment.”
