CPT CODE and description
84152 – Prostate Specific Antigen (PSA); Complexed (Direct Measurement)
84153 – Prostate Specific Antigen (PSA); Total – average fee amount – $30 – $40
84154 – Prostate Specific Antigen (PSA); Free
G0102 Prostate cancer screening; digital rectal examination
G0103 – Prostate Cancer Screening; Prostate Specific Antigen Test (PSA)
Prostate Specific Antigen (PSA)
Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer. Three to 6 months after radical prostatectomy, PSA is reported to provide a sensitive indicator of persistent disease. Six months following introduction of antiandrogen therapy, PSA is reported of distinguishing patients with favorable response from those in whom limited response is anticipated.
PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer. PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment. UnitedHealthcare Community Plan reimburses for Prostate Specific Antigen (PSA) (CPT code 84153), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-9-CM and ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member’s condition.
Why doesn’t Medicare cover a Prostate Specific Antigen (PSA) test for my patients with benign prostatic hypertrophy (BPH)?
The code for BPH, 600.00, is not on the ICD-9-CM Codes Covered by Medicare listing for a diagnostic PSA. Medicare does, however, cover an annual screening PSA test for men over 50. Men with BPH receiving an annual PSA screening should have their claims coded with procedure code G0103 in lieu of CPT code 84153. This screening procedure code requires a diagnosis code of V76.44 that must appear on the claim form. If the patient has symptoms of prostate carcinoma along with the BPH, such as hematuria, nocturia, urinary frequency, and slow stream, a diagnostic PSA can be covered.
Prostate Cancer Screening Tests and Procedures, states that the revenue code 770 is
to be used with HCPCS code G0102, digital rectal examination; and revenue code 30X is to be used
with HCPCS code G0103, prostate specific antigen blood test
Prostate Cancer Screening Tests and Procedures, states that the revenue code 770 is to be used with HCPCS code G0102, digital rectal examination; and revenue code 30X is to be used with HCPCS code G0103, prostate specific antigen blood test.
PROSTATE CANCER SCREENING TESTS AND PROCEDURES
A. Coverage Requirements.–Section 4103 of the Balanced Budget Act of 1997 provides for coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations. Effective for services furnished on or after January 1, 2000, Medicare will cover prostate cancer screening tests/procedures for the early detection of prostate cancer. Coverage of prostate cancer screening tests includes the following procedures furnished to an individual for the early detection of prostate cancer:
o Screening digital rectal examination.
o Screening prostate specific antigen (PSA) blood test.
1. Screening digital rectal examinations are covered at a frequency of once every 12 months for men who have attained age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months have passed following the month in which the last Medicare-covered screening digital rectal examination was performed. Screening digital rectal examination means a clinical examination of an individual’s prostate for nodules or other abnormalities of the prostate.
This screening must be performed by a doctor of medicine or osteopathy (as defined in §186l (r)(1) of the Act), or by a physician assistant, nurse practitioner, clinical nurse specialist, or by a certified nurse mid-wife (as defined in §1861(aa) and §1861(gg) of the Act), who is authorized under State law to perform the examination, fully knowledgeable about the beneficiary, and would be responsible for explaining the results of the examination to the beneficiary.
2. Screening PSA tests are covered at a frequency of once every 12 months for men who have attained age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months have passed following the month in which the last Medicare-covered screening prostate specific antigen test was performed. Screening PSA is a test that measures the level of prostate specific antigen in an individual’s blood. This screening must be ordered by the beneficiary’s physician or by the beneficiary’s physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife (the term “physician” is defined in §1861 (r)(1) of the Act to mean a doctor of medicine or osteopathy and the terms “physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife” are defined in §1861 (aa) and §1861 (gg) of the Act) who is fully knowledgeable about the beneficiary, and who would be responsible for explaining the results of the test to the beneficiary.
B. Billing Requirements.–Follow the general bill review instructions in §3604 of the Medicare Intermediary Manual, Part 3. The provider will bill on Form HCFA-1450 or electronic equivalent. The appropriate bill types are 12X, 13X, 14X, 22X, 23X, 71X, 73X, 75X, and 85X.
The following HCPCS and revenue codes should be used for prostate screening:
o G0102 – Use revenue code 770, prostate cancer screening; digital rectal examination.
o G0l03 – Use revenue code 30x, prostate cancer screening; prostate specific antigen testing
Medicare allows for coverage of both screening and diagnostic Prostate Specific Antigen (PSA) tests. Screening PSA tests are defined as those that are performed in the absence of signs or symptoms of prostate cancer. Diagnostic PSA tests are defined as those performed when the patient has signs or symptoms.
If a patient has no signs or symptoms of prostate cancer, submit the appropriate code for a screening PSA
If a patient does have signs or symptoms of prostate cancer, submit the appropriate code for a diagnostic PSA. Signs or symptoms may include a personal history of prostate cancer, and urinary tract signs and symptoms with a palpably abnormal prostate on physical examination.
Submit HCPCS code G0103 for screening PSA tests
Medicare coverage for screening PSAs is limited to once every 12 months
CPT codes for diagnostic PSA tests are 84152, 84153 and 84154
Payment Requirements Intermediaries.–
o G0102 – digital rectal examination – Deductible and coinsurance apply. Payment varies depending on the facility providing the service as follows:
12X = Outpatient Prospective Payment System
13X = Outpatient Prospective Payment System
14X = Outpatient Prospective Payment System
22X = Reasonable Cost
23X = Reasonable Cost
71X = All Inclusive Rate
73X = All Inclusive Rate
75X = Medicare Physician Fee Schedule
85X = Cost (Payment should be consistent with amounts you pay for code 84153 or code 86316.)
o G0103 – antigen test – pay under the clinical diagnostic lab fee schedule. Use CPT code 99211 as a guide. Deductible and coinsurance apply.
D. Calculating Frequency.–To determine the 11 month period, start the count beginning with the month after the month in which a previous test/procedure was performed.
Prostate cancer screening digital rectal examinations (DRE)
and screening prostate specific antigen (PSA) blood tests
must be billed using screening (“V”) code V76.44 (Special
Screening for Malignant Neoplasms, Prostate)
Medicare Provides Coverage of the Following Prostate Cancer Screening Tests:
• Screening digital rectal examination (DRE), and
• Screening prostate specific antigen (PSA) blood test.
Eligibility and Frequency
Medicare provides coverage of an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male beneficiaries age 50 and older (coverage begins the day after the beneficiary’s 50th birthday), if at least 11 months have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed for the early detection of prostate cancer.
When calculating frequency, to determine the 11-month period, the count starts beginning with the month after the month in which a previous test/procedure was
EXAMPLE: The beneficiary received a screening PSA test in January 2006. The count starts beginning February 2006. The beneficiary is eligible to receive another screening PSA test in January 2007 (the month after 11 months have passed)
Medicare National Coverage Determination Policy
Abn findings on dx imaging of abd regions, inc retroperiton R93.5
Abnormal findings on diagnostic imaging of limbs R93.6
Abnormal findings on diagnostic imaging of prt ms sys R93.7
Abnormal results of function studies of organs and systems R94.8
Benign essential microscopic hematuria R31.1
Bladder-neck obstruction N32.0
Carcinoma in situ of prostate D07.5
Disorder of prostate, unspecified N42.9
Elevated prostate specific antigen [PSA] R97.2
Enlarged prostate with lower urinary tract symptoms N40.1
Enlarged prostate without lower urinary tract symptoms N40.0
Feeling of incomplete bladder emptying R39.14
Frequency of micturition R35.0
Gross hematuria R31.0
Hematuria, unspecified R31.9
Hesitancy of micturition R39.11
Inflammatory disease of prostate, unspecified N41.9
Malignant neoplasm of bladder neck C67.5
Malignant neoplasm of prostate C61
Neoplasm of uncertain behavior of prostate D40.0
Neoplasm of unsp behavior of other genitourinary organs D49.5
Nodular prostate with lower urinary tract symptoms N40.3
Nodular prostate without lower urinary tract symptoms N40.2
Obstructive and reflux uropathy, unspecified N13.9
Other microscopic hematuria R31.2
Personal history of malignant neoplasm of prostate Z85.46
R39.12 Poor urinary stream
Retention of urine, unspecified R33.9
Sec and unsp malig neoplasm of inguinal and lower limb nodes C77.4
Sec and unsp malig neoplasm of nodes of multiple regions C77.8
Secondary and unsp malignant neoplasm of intrapelv nodes C77.5
Secondary malignant neoplasm of bone C79.51
Secondary malignant neoplasm of bone marrow C79.52
Secondary malignant neoplasm of genital organs C79.82
Straining to void R39.16
Unspecified urinary incontinence R32
Urgency of urination R39.15
Encounter for screening for malignant neoplasm of prostate Z12.5