When is a non-screening PSA covered by Medicare?

July 1, 2011

The coverage, and subsequent payment, for a PSA test is determined by the contractual agreement with the patient's insurance company. Some insurance companies pay and others do not for procedures and other services with different diagnoses.

Medicare developed a "national payment determination" several years ago that identified a finite number of diagnoses for which they would support payment for a PSA test. "Hypogonadism" was not one of those diagnoses. If the PSA test is ordered with one of the diagnoses, such as cancer of the prostate, elevated PSA level, etc., Medicare will pay for it any number of times that the test is considered to be medically necessary during the year, but they will not pay for a PSA test for any other diagnoses, other than a "screening" test, as discussed below.

We would recommend that, in addition to appealing the denial, you ask your doctor to write a letter to the AUA asking them to petition Medicare to add hypogonadism to the list of diagnoses to be paid for a non-screening PSA test.

Q. I am very frustrated by payers requiring pre-authorization for patients when I order testosterone gel patches. On numerous occasions, I have written a prescription only to have the pharmacist inform me that the patient's insurance company requires pre-authorization. I called the insurance company, was put on hold, and was then referred to their Web site. After spending approximately 30 minutes filling out a form, I was informed that the pre-authorization could not be done on the Web site and that I should call another number. What can I do?

A. The required pre-authorization is a coverage issue between the patient and his insurance company. You should not spend your time dealing with coverage issues on a prescription drug. That is the patient's problem. In fact, the difficulty you experience will never be corrected unless the purchaser of the insurance-the patient or his employer-deals with the insurance company directly to correct the "delaying tactics" that the insurance company has implemented.

We would provide the patient with the information he needs, such as diagnosis, reason for the medication, and the reason you've ordered it. Avoid spending time after the office visit dealing with pre-authorization. If the pharmacist calls, have your office refer him to the patient for the pre-authorization.

Also, we would instruct the patient to call his employer (if the employer is the purchaser of the insurance) for assistance.

Q. A colleague told me that you had mentioned at a seminar that we no longer needed to use a –25 modifier on the evaluation and management code when a patient is seen on the same day that we have performed a uroflow test. Is this true? If so, why? That is against everything I've ever read or heard.

A. The simple answer is yes, it is true. For Medicare, you no longer need to use a –25 modifier on an E&M code when billed in conjunction with uroflow (51741–complex uroflowmetry or 51736–simple uroflowmetry).

The reason is very simple: Medicare changed the rules. As you may recall, in the 2011 Medicare fee schedule, uroflow was one of the big losers. The payment for both the complex and the simple uroflow was decreased significantly. Part of the reason was that it was changed from a global period of "000" to "XXX," removing it from the global edits for same-day procedures. As you have heard many times before, you should be paid for your E&M code in addition to all non-global codes, such as x-ray and laboratory, without the use of a modifier.

The two uroflow codes mentioned above, along with the bladder scan for residual urine (51798), the donor nephrectomy codes, and the intersex change codes, are the only codes in the urology section of the CPT (50000-55980 codes) that are "XXX" non-global.

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.