Proper Billing Procedure for PSA Screening
For proper reimbursement of PSA screening, use the appropriate preventive service code G0103 for Medicare patients and CPT code 84153 with appropriate screening diagnosis codes for commercial insurance.
Medicare Billing Guidelines
- Use HCPCS code G0103 (Prostate cancer screening; prostate specific antigen test) for Medicare patients receiving a screening PSA test 1
- Medicare covers annual PSA screening for men age 50 and older with no cost-sharing for the patient 1
- Include appropriate ICD-10 diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate) to indicate the preventive nature of the service 1
- For Medicare patients with higher risk factors (African American race or family history), document these risk factors in the medical record to support earlier screening at age 45 1
Commercial Insurance Billing Guidelines
- Use CPT code 84153 (Prostate specific antigen, total) for commercial insurance patients 1
- Include appropriate ICD-10 diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate) 1
- For patients with family history of prostate cancer, consider using additional code Z80.42 (Family history of malignant neoplasm of prostate) to support medical necessity for earlier or more frequent screening 2
- For African American patients, document this risk factor in the medical record as it may support medical necessity for earlier screening 1
Frequency and Documentation Requirements
- Document that the patient was informed about the benefits and potential harms of PSA screening prior to ordering the test 2
- For average-risk men, annual screening typically begins at age 50 if life expectancy is at least 10 years 1
- For high-risk men (African American race or family history of prostate cancer), document that screening was initiated at age 45 1
- Clearly document the medical necessity for the screening test in the patient's chart 2
Common Billing Pitfalls to Avoid
- Avoid using diagnostic codes for symptoms (such as urinary symptoms) when the test is truly for screening purposes, as this may result in incorrect patient cost-sharing 2
- Do not use diagnostic PSA codes (84153 without screening diagnosis) for screening purposes as this may result in inappropriate patient billing 1
- Be aware that some commercial payers may have specific coverage limitations or frequency restrictions for PSA screening 1
- For Medicare patients, ensure the G0103 code is used rather than the general CPT code to ensure proper coverage under preventive benefits 1
Special Billing Situations
- If a patient has both screening and diagnostic indications, document both reasons but bill with the primary indication that prompted the test 1
- For patients on active surveillance for previously diagnosed prostate cancer, use diagnostic codes rather than screening codes 2
- When PSA testing is performed as part of a comprehensive preventive visit, ensure both services are appropriately coded 1
- For patients taking medications that affect PSA levels (finasteride, dutasteride), document this in the medical record as it may impact interpretation 1