When a urologist performs a prostate specific antigen (PSA) test in the presence of signs or symptoms of prostate cancer, the diagnosis code determines whether you will be reimbursed. HCFA has no national policy for coverage of nonroutine PSA testing, so each carrier has its own local medical review policy (LMRP) indicating what diagnosis codes justify medical necessity for 84154 (prostate specific antigen [PSA]; free) and CPT 84153 (prostate specific antigen [PSA]; total).
Some carriers have LMRPs only for 84153, which is covered by more diagnosis codes than 84154. Policies that refer to both PSA testing codes, however, do not distinguish between diagnosis codes by CPT code, but have overall medical necessity lists for both 84153 and 84154. Some carriers do not reimburse total and free PSA tests on the same day.
Distinguish Between 84153 and 84154
Free PSA (84154) helps discover borderline elevations of total PSA (84153). Free PSA may be done after a total PSA to find out if there is a borderline elevation. Total PSA lacks the specificity needed to determine whether the condition is benign or cancerous. Both tests together provide a ratio of free/total PSA, which when used with the total PSA gives the urologist a more direct indication of the presence of prostate cancer compared to benign enlargement, also known as benign prostatic hyperplasia (BPH).
Total PSA is the more commonly performed test. It can indicate the possible presence of prostate cancer in, for example, a patient with BPH. Total PSA can also follow the progress of a prostate tumor once diagnosed and follow prostate cancer patients who have had treatment but must be monitored to detect metastatic or persistent disease.
BPH Diagnosis May Cause Denials
BPH is the main diagnosis urologists use when performing screening PSA tests, explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stonybrook. Significantly, many carriers wont pay for BPH diagnosis codes. Many urologists order PSA testing for the diagnoses in the 600 series, some of which are covered by some carriers, such as 600.x (hyperplasia of prostate), 601.x (inflammatory diseases of prostate) and 602.x (other disorders of prostate). But when a urologist uses one of the 600 series of prostate hyperplasia diagnosis codes, the payer may deny the claim. Some carriers do not cover 84153, the procedure used for the screening PSA, with any of these diagnosis codes.
It varies not only from carrier to carrier but for different areas within a carrier system, Ferragamo notes. Check with your carrier for covered diagnosis codes.