Prostate-specific antigen (PSA) testing is a routine procedure in urology practices. Accurate Psa Coding is therefore essential for ensuring proper reimbursement and minimizing claim denials. Incorrect coding can lead to significant revenue loss for your practice. To help you navigate the nuances of PSA test coding and optimize your billing processes, we’ve compiled three crucial tips based on expert guidelines.
Differentiating Screening vs. Diagnostic PSA Tests for Correct Coding
The first step in accurate PSA coding is to determine whether the test is being performed for screening purposes or as a diagnostic measure. This distinction is critical as payers, especially Medicare, often have different coding requirements for each category. Delving into the urologist’s documentation is key to making this determination.
For Medicare patients, screening PSA tests should be reported using code G0103 (Prostate cancer screening; prostate specific antigen test (PSA)). Conversely, diagnostic PSA tests are coded using one of the following CPT® codes, depending on the specific type of PSA assay performed:
- 84152: Prostate specific antigen (PSA); complexed (direct measurement)
- 84153: Prostate specific antigen (PSA); total
- 84154: Prostate specific antigen (PSA); free
Important Note: In urology settings, CPT® code 84153 is the most frequently used code for PSA testing. Code 84152 is less common, and 84154 is typically reserved for situations where a prior PSA elevation is already known.
To differentiate between screening (G0103) and diagnostic (8415X) PSA coding, carefully review the urologist’s notes. If the patient is asymptomatic and the notes lack any indication of urological or prostate issues, then G0103 is the appropriate code for a screening PSA. However, if the urologist orders the PSA test due to specific signs or symptoms, such as documenting a firm prostate gland during a rectal exam, the test is considered diagnostic, and you should utilize code 84153.
When an Evaluation and Management (E/M) service is performed during the same patient encounter as a diagnostic PSA test, both the PSA test code and the relevant E/M code can typically be reported separately. Modifier 25 is generally not required for the E/M service in this scenario, as PSA laboratory tests do not have a global period.
Selecting Appropriate ICD-10 Diagnosis Codes for PSA Coding
Choosing the correct ICD-10 diagnosis code is as crucial as selecting the right CPT® code for PSA coding. The diagnosis code must support the medical necessity of the PSA test.
For screening PSA tests (coded with G0103) in asymptomatic patients, the only acceptable primary diagnosis code is Z12.5 (Encounter for screening for malignant neoplasm of prostate). Medicare will deny claims for screening PSAs submitted with any other primary diagnosis code. It is imperative to link a screening diagnosis with the screening CPT® code G0103.
For diagnostic PSA tests, the appropriate diagnosis coding depends on the clinical scenario and findings. If the PSA test is ordered due to a previously elevated PSA level, report R97.20 (Elevated prostate specific antigen [PSA]).
If the diagnostic PSA test results are normal, but the test was ordered due to symptoms, consider codes related to benign prostatic hyperplasia (BPH), such as:
- N40.0: Benign prostatic hyperplasia without lower urinary tract symptoms
- N40.1: Benign prostatic hyperplasia with lower urinary tract symptoms
In cases where the urologist documents a definitive diagnosis like prostate cancer, utilize the specific malignancy code, for example, C61 (Malignant neoplasm of prostate). If only signs and symptoms are noted, codes such as R39.11 (Hesitancy of micturition) might be appropriate. Medicare and other payers generally accept a range of diagnosis codes indicative of urological signs or symptoms for diagnostic PSA tests, including:
- R31.0: Gross hematuria
- R31.1: Benign essential microscopic hematuria
- R35.0: Frequency of micturition
- R35.1: Nocturia
This list is not exhaustive, and it is crucial to remember that each payer may have its own specific list of acceptable diagnosis codes for PSA testing coverage. Always consult payer-specific guidelines.
Adhering to Frequency Limitations in PSA Test Coding
The final, yet critical, aspect of accurate PSA coding is being mindful of payer-imposed frequency limitations for PSA tests. Payers have established guidelines regarding how often they will reimburse for PSA screenings and diagnostic tests.
Medicare, for instance, covers screening PSA tests (G0103) only once every 12 months for men aged 50 and older, as detailed in the Medicare Claims Processing Manual, Chapter 18, Section 50. Ensure that at least 11 full months have passed since the patient’s previous PSA screening test to avoid denial due to frequency limits. This is irrespective of which provider ordered the prior screening; a PSA screening performed at a primary care physician’s office within the past year will count against Medicare’s frequency limit.
If a patient requires a PSA test sooner than the allowed frequency, you can still perform the test. However, to protect your practice’s revenue, it is essential to obtain an Advance Beneficiary Notice (ABN) from the patient prior to the test. The ABN informs the patient that Medicare may not cover the test due to frequency limitations and that they will be financially responsible if the claim is denied.
To ensure compliant PSA coding and billing, always verify payer-specific guidelines and Local Coverage Determinations (LCDs) for screening frequencies and acceptable diagnostic codes for both screening and diagnostic PSA tests. Regardless of payer rules, comprehensive documentation in the patient’s medical record is paramount to support your coding choices.
Resource:
Medicare Claims Processing Manual, Chapter 18, section 50, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18pdf.pdf
By mastering these three key tips, you can significantly improve the accuracy of your PSA coding, reduce claim denials, and ensure appropriate reimbursement for your urology practice. Staying informed and diligent in your coding practices is crucial for financial success and compliance.
This information is for educational purposes only and should not be considered medical or legal advice. Always consult with relevant coding guidelines and payer regulations for specific situations.
