Prostate-specific antigen testing, Medicare

Applies to:

Medicare Advantage plans

Definition

A prostate-specific antigen (PSA) blood test screens for prostate cancer by measuring the amount of PSA, a protein produced by tissue in the prostate.

PSA testing coverage

All plans cover diagnostic PSA testing.

Only Medicare covers preventive PSA tests. Medicare covers an annual preventive PSA prostate cancer screening test once every 12 months for all male beneficiaries age 50 and older. Coverage begins the day after the beneficiary's 50th birthday.

PSA testing billing

Payable: When ordered and billed according to the instructions below

Not payable: When billed with diagnosis Z0.0

When ordering during an annual physical or other office visit or through standing orders, remember the lab will have to determine the "reason" for the order, and the lab method for the test.

A PSA test ordered with Z0.0, a routine medical examination, means the lab will issue a notice of non-coverage and the patient may be responsible for the full cost of services that, when ordered correctly, are covered under Medicare.

Ordering and billing preventive screening PSA tests

When a Medicare patient is asymptomatic and has not been diagnosed with, is not suspected of having, and is not being treated for a condition related to the prostate:

• Bill G0103: Prostate cancer screening, prostate-specific antigen (PSA), total
• Use ONLY diagnosis code Z12.5: Screening for malignant neoplasms of prostate. No other diagnosis code is covered by Medicare for a preventive screening PSA.

Ordering and billing diagnostic screening PSA tests

When the patient has been diagnosed with, is suspected of having, or is being treated for a condition related to the prostate:

• Bill 84153: Prostate-specific antigen (PSA), total
• Use the diagnosis code for the condition being treated. See Section 190.31 of the Medicare National Coverage Determinations (NCD) Coding and Policy Manual and Change Report for information on what conditions are considered medically and reasonably necessary.
• Conditions not covered by Medicare: If the condition being treated is not listed in 190.31, before ordering the test, request a pre-service organization determination. See the Medicare non-coverage section for how to request one.