College of American Pathologists

  Prostate cancer screening
  claims and codes


Reprinted from July 1999 CAP TODAY

Medicare has given its carriers instructions on how to handle claims for Prostate cancer screenings required by the Balanced Budget Act of 1997.

The 1997 law made numerous changes to Medicare, including expanding the program's coverage of preventive care. Under the law, Medicare will cover annual Prostate cancer screenings, starting Jan. 1, for men who are a minimum age of 50 years. Covered screenings include digital rectal examination and prostate-specific antigen tests.

A recent program transmittal from the Health Care Financing Administration instructs carriers that claims for prostate cancer screening tests should be submitted on Health Insurance Claim Form HCFA-1500 or an electronic equivalent.

Providers should use HCPCS code G0102 for the digital rectal examination and code G0103 for PSA blood testing. HCFA said carriers should set payment for G0102 on a reasonable cost basis using CPT code 99211 as a guide. Further, carriers should pay for G0103 under the clinical laboratory fee schedule consistent with the amounts paid for CPT codes 84153 or 86316.

The digital rectal examination must be performed by, and the PSA test must be ordered by, a doctor of medicine or osteopathy, physician assistant, nurse practitioner, clinical nurse specialist, or certified midwife, reported HCFA.

Also beginning Jan. 1, the Common Working File will include prostate cancer screening edits that check claims for proper age, test or procedure frequency, gender, and HCPCS code.