CPT Code G0103 Information

CPT Code:

  • G0103


  • CPT code G0103 refers to a Prostate Specific Antigen (PSA) test which is a screening method for prostate cancer. This is used primarily in a diagnostic laboratory setting.

Insurance Guidelines:

Medicare covers PSA screening (G0103) annually for men over the age of 50, assuming that at least 11 months have passed since the last screening. This test is considered preventative and is intended for use without signs or symptoms of prostate disease. Different payers may have specific guidelines, so it’s crucial to check with individual insurance providers.

CPT Code Guidelines and Usage:

G0103 should be used for annual screening PSA tests in the absence of symptoms or signs of prostate cancer.
For Medicare, documentation should support the medical necessity of the test, including an absence of signs and symptoms of prostate cancer. The test should be ordered by a qualified healthcare provider familiar with the patient’s health status.

Top 5 Denials:

Lack of medical necessity: Screening tests performed without clear indications or documentation supporting the absence of symptoms can lead to denials.

Frequency limits: Claims may be denied if the test is performed more frequently than the allowed once per year.

Incorrect billing: Errors in using the correct HCPCS code or incorrect diagnostic codes associated with the claim.

Provider eligibility issues: Tests not ordered by eligible healthcare providers or those lacking proper credentials.

Lack of prior authorization: Some insurers may require prior authorization for the screening test.

Coverage Indications, Limitations, and/or Medical Necessity

Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict
residual tumor in the post phase of prostate cancer. Three to 6 months after radical prostatectomy, PSA
is reported to provide a sensitive indicator of opera tive per sistent disease. Six months following
introduction of antiandrogen therapy, PSA is reported of distinguishing patients with favorable 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 response ma king process for diagnosing prostate cancer. PSA also, serves as a
marker in following the progress of most prostate tumors once a has been established. This test is also
an aid in the management of prostate cancer patients and in detecting metastatic or p di ers agnosis
istent disease in patients following treatment.

PSA is of proven value in differentiating benign from malignant disease in men with lower urinary tract
signs & symptoms (e.g hematuria, slow urine stream, hesitancy, urgency, frequency, ., nocturia &
incontinence) as well as with patients with palpably abnormal prostate glands on physician exam, and in
patients with other laboratory or imaging studies that suggest the possibility of a ma prostate disorder.
PSA is also a marker used to follow the progress of prostate cancer once a diagnosis has been
established, detecting metastatic or persistent disease in patients who may require additional
treatment. PSA testing may also be useful i lignant su ch as n t differential diagnosis of men presenting
with Limitations as yet undiagnosed disseminated metastatic disease.

PSA Screen Test Order/Medical Necessity Coding Information Epic order # LAB3063 PSA screen (HCPCS
G0103) ICD-10 Support Medical Necessity

creening Prostate Specific Antigen Tests Screening prostate specific antigen tests are covered at a
frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed
following the month in which the last Medicare-covered screening prostate specific antigen test was
performed). Screening prostate specific antigen tests (PSA) means a test to detect the marker for

adenocarcinoma of prostate. PSA is a reliable immunocytochemical marker for primary and metastatic
adenocarcinoma of prostate. 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 “attending 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’s medical condition, and who would be responsible for using the results of any examination
(test) performed in the overall management of the beneficiary’s specific medical problem.