Key takeaways
- A PSA done to screen a man with no symptoms is billed as G0103 with diagnosis Z12.5. A PSA done because of symptoms or a known condition is a diagnostic test billed as 84153.
- Medicare covers the screening PSA once a year for men aged 50 and older, with no deductible and no coinsurance.
- The screening digital rectal exam, G0102, does bring a deductible and coinsurance, and it bundles into a same-day E/M visit.
Screening and diagnostic PSA are different claims
The lab test is the same blood draw. What changes is why it was ordered, and that decides the code, the diagnosis and what the patient owes. A claim coded the wrong way is either denied or leaves the patient with a bill they did not expect.
| Screening PSA | Diagnostic PSA | |
|---|---|---|
| Code | G0103 | 84153 |
| Why it was ordered | No symptoms, routine check | Symptoms, an abnormal exam or a known condition |
| Diagnosis | Z12.5, encounter for screening for malignant neoplasm of prostate | The symptom or condition that justified the test |
What Medicare pays for screening
Noridian Medicare, one of the Medicare contractors, publishes the screening rules on its prostate cancer screening page:
- Men aged 50 and older are covered, starting the day after the 50th birthday.
- Screening is covered annually.
- G0103, the PSA test, has the copayment or coinsurance waived and the deductible waived.
- G0102, the digital rectal exam, is subject to the deductible and coinsurance.
- G0102 is bundled into a covered E/M service when both are done on the same day.
Most commercial plans follow the same idea for preventive care, but age limits, frequency and cost sharing are set by each plan, so check each payer.
When a screening PSA turns into a diagnostic one
A visit often starts as screening and changes. If the patient reports urinary symptoms, the exam is abnormal, or a prior PSA was elevated, the PSA is no longer routine. Code it as the diagnostic test with the diagnosis that justifies it, and do not leave Z12.5 on the claim. The order and the visit note should show the reason, so the code can be defended.
Mistakes that cause denials or patient bills
- G0103 more than once a year. A second screening PSA inside the annual limit is denied.
- Z12.5 on a diagnostic test. The diagnosis says screening while the record says symptoms.
- 84153 for a patient with no symptoms. This can be denied as not medically necessary, and the patient may owe the cost.
- Billing G0102 separately on an E/M day. It is bundled, so the line is not paid.
- Not telling the patient. A diagnostic PSA carries normal cost sharing. Explain this before the draw.
Sources
Medicare screening rules, codes, diagnosis and cost sharing: Noridian Medicare, Prostate Cancer Screening (Part B). The diagnostic PSA description follows the CPT code set. Check your own contractor, the lab fee schedule rules and each commercial payer for current policy.
PSA billing questions
What is the difference between G0103 and 84153?
G0103 is the screening PSA for a man with no symptoms, billed with diagnosis Z12.5. 84153 is the diagnostic PSA, ordered because of symptoms, an abnormal finding or a known condition, billed with the diagnosis that supports it.
How often does Medicare cover a screening PSA?
Once a year for men aged 50 and older, starting the day after the 50th birthday. Noridian Medicare waives the deductible and coinsurance for G0103.
Can I bill the digital rectal exam with the PSA?
G0102 is the screening digital rectal exam. It is covered annually but the deductible and coinsurance apply, and it is bundled into a covered E/M visit when both happen the same day.
What happens if the patient has symptoms at a screening visit?
The PSA is then diagnostic. Bill 84153 with the diagnosis that justifies it instead of G0103 with Z12.5, and document the reason in the order and the visit note.