Is reimbursement for repeat PSA testing possible?

January 1, 2010

Unfortunately, there is no code for "history of elevated PSA."

Let's consider the PSA test first. Once the patient's PSA has returned to normal, repeat PSAs would be considered "screening." Medicare pays for a screening PSA test only once per year. If the patient is insured by Medicare and you decide to obtain a PSA at 6-month intervals, have the patient sign an advance beneficiary notice and ask him to pay for the second PSA obtained in that 12-month period.

The office visit is a separate problem. Although the rule states that you should code to the highest level of knowledge at the end of the encounter, we think you're justified in charging for the "reason the patient was seen" for the first encounter in which the PSA returned to normal. Following that visit, if the patient is not being evaluated for any other problems, then you would need to use a screening, or "well patient," code. Obviously, if the patient had another problem that was also being evaluated, you would use that diagnosis code for the office visit.

There are a number of V codes listed in the "Supplementary Classification Of Factors Influencing Health Status And Contact With Health Services" of the ICD-9 book (also see . We do not think any of these would work, unless you feel strongly that V15 ("other personal history presenting hazards to health") would apply.

Q A fellow coder was told at a recent seminar that bladder tumors now have to indicate tumor size-ie, small, medium, or large-by metric measurement in the operative report, or Medicare will only allow for a small tumor to be billed. Is this correct?

A Medicare has required the documentation of the size of a bladder tumor since it switched to its new payment system in 1992. Fortunately, the urologist can estimate tumor size at the time of surgery. Medicare clarified its rules a number of years ago to indicate that one cannot add tumors together to create a larger size; billing must be based on the size of the largest tumor. If a chart is audited and the operative note did not state the size of the tumor, then Medicare will pay only for a small tumor. If size is documented, Medicare will pay the appropriate code.

Note that the CPT code also includes bladder tumor size in centimeters. In the code description, this is the key documentation that should be pointed out to your fellow coders.

Q Please tell me the code for a transuretheral nephroscopy with laser lithotripsy of a kidney stone using a flexible scope.

A The correct code would be 52353 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]). Pyeloscopy is a part of the definition of the code. We think you will agree that the remainder of the description is accurate.

It is unfortunate that those procedures that require an excessive amount of time and effort, as many renal stones do, are paid at the same rate as the "easy" lithotripsy of a ureteral calculus. However, those are the rules, and there is no other option.

ModernMedicine NETWORK


Urologists face reimbursement cuts and newly invalid codes in 2010, according to Ray Painter, MD, and Mark Painter. Read:

Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.