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Prostate Cancer Screening Tests and Procedures

The Health Care Financing Administration issued changes to the Medicare Carriers Manual §4182 Prostate Cancer Screening Tests and Procedures effective for services rendered on and after January 1, 2001.

Please note sections 4182.3 - HCPCS Codes and Payment Requirements stating a beneficiary must be over 50 years of age and deleting the reference to 'attending' physicians; and 4182.7 - Diagnosis Coding Requirements stating the appropriate screening 'V' code to be used when billing for prostate cancer screening tests or procedures.

The following sections summarize coverage requirements and detail claims processing procedures for prostate cancer screening tests and procedures.

4182.1 Coverage Summary.--Sections 1861(s)(2)(P) and 1861(oo) of the Social Security Act (as added by §4103 of the Balanced Budget Act of 1997), provide for coverage of certain prostate cancer screening tests and procedures subject to certain coverage, frequency, and payment limitations. Effective for services furnished on or after January 1, 2000, Medicare will cover prostate cancer screening tests and procedures for the early detection of prostate cancer.

Coverage currently consists of the following tests and procedures furnished to an individual for the early detection of prostate cancer:

  • Screening Digital Rectal Examination.--This test is a clinical examination of an individual's prostate for nodules or other abnormalities of the prostate; and
  • B. Screening Prostate Specific Antigen (PSA) Blood Test.--This test detects the marker for adenocarcinoma of the prostate.

For more information regarding coverage of prostate cancer screening tests and procedures, refer to §50-55 of the Coverage Issues Manual.

4182.2 Requirements for Submitting Claims.--Submit claims for prostate cancer screening tests on Health Insurance Claim Form CMS-1500 or electronic equivalent.

Follow the general instructions in §2010, Purpose of Health Insurance Claim Form CMS-1500, Medicare Carriers Manual, Part 4, Chapter 2. 4182.3 HCPCS Codes and Payment Requirements.--The following table lists coverable codes and services for prostate cancer screening tests and procedures. Pay for these services according to the appropriate fee schedule when all of the requirements noted are met.

HCPCS Code; Type of Service(TOS)
Description
Payment
Requirements
Methodology/Fee Schedule

G0102; TOS=1

Prostate cancer screening; digital rectal examination

1. Performed on a male Medicare beneficiary over 50 years of age (i.e., for services starting at least one day after the beneficiary attained age 50).

2. Performed by one of the following, who is authorized under State law to perform the examination, is fully knowledgeable about the beneficiary, and is responsible for explaining the results of the examination to the beneficiary:

a. Doctor of medicine or osteopathy
b. Qualified physician assistant
c. Qualified nurse practitioner
d. Qualified clinical nurse specialist
e. Qualified certified nurse midwife

3. Performed at a frequency no greater than once every 12 months (See §4182.4).

1. Refer to the physician's fee schedule.

2. Apply deductible and coinsurance.

3. Claims from physicians for these examinations where assignment was not taken are subject to the Medicare limiting charge. (See §7555).4. Correct Coding Initiative requirements apply. See §4182.6

G0103; TOS=5

Prostate cancer screening; PSA test

1. Performed on a male Medicare beneficiary over 50 years of age (i.e., for services starting at least one day after the beneficiary attained age 50)

2. Ordered by one of the following, who is authorized under State law to perform the examination, is fully knowledgeable about the beneficiary, and is responsible for explaining the results of the examination to the beneficiary:

a. Physician (doctor of medicine or osteopathy)
b. Qualified physician assistant
c. Qualified nurse practitioner
d. Qualified clinical nurse specialist
e. Qualified certified nurse midwife

3. Performed at a frequency no greater than once every 12 months. (See §4182.4.)

1. Refer to the clinical laboratory fee schedule; payment for this test is the same as for code "84153, PSA; total."

2. Do not apply deductible and coinsurance.

4182.4 Calculating the Frequency.--Once a beneficiary has received any (or all) of the covered prostate cancer screening test/procedures, he may receive another (or all) of such test/procedures after 11 full months have passed. To determine the 11-month period, start your count beginning with the month after the month in which any (or all) of the previous covered screening test/procedures was performed.

EXAMPLE: The beneficiary received a screening PSA test on February 25, 2000. Start your count beginning March 2000. The beneficiary is eligible to receive another screening PSA test on February 1, 2001 (the month after 11 months have passed.) 4182.6 Correct Coding Requirements.--Billing and payment for a Digital Rectal Exam (DRE) (G0102) is to be bundled into the payment for a covered E/M service (CPT codes 99201-99456 and 99499) when the two services are furnished to a patient on the same day. If the DRE is the only service or is provided as part of an otherwise non-covered service, HCPCS code G0102 would be payable separately if all other coverage requirements are met.

4182.7 Diagnosis Coding Requirements.--There are no specific diagnosis requirements for prostate screening tests and procedures. However, prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using screening ("V") code V76.44 (Special Screening for Malignant Neoplasms, Prostate).

 

 
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