(Reproduced by permission from Medicare Focus, August, 1997, pp. 37 - 39.)

Medicare Part A
Local Medical Review Policy
Prostate Specific Antigen (PSA)

Policy Number: 96-09

Description

84153 Prostate specific antigen (PSA)

Type of Bill: 13X, 14X, 22X, 23X, 71X, 74X, 75X

Revenue Codes: 300 - 319

Indications and Limitations

This test is performed to aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment.

HCPCS Codes: 84153

Diagnosis Codes for Coverage

ICD-9-CM Code Description
185
188.5
188.8		 Malignant Neoplasm of Genitourinary Organs
198.82 Malignant Neoplasm of Other and Unspecified Sites
222.2 Benign Neoplasms
233.4 Carcinoma In Situ
236.5 Neoplasms of Uncertain Behavior
239.5 Neoplasms of Unspecified Nature
596.0 Other Diseases of Urinary System
790.93 Nonspecific Abnormal Findings
V10.46 Persons With Potential Health Hazards Related To Personal and Family History


ICD-9 diagnosis codes should be used at their highest level of specificity.

Category:

Pathology and Laboratory

Reason for Denial

Routine screening.

The following text is added per Medicare Focus January, 2002
Screening Prostate Antigen (PSA) test for Prostate Cancer Screening should be billed with ICD-9-CM code V76.44 and HCPCS code G0103. Payment cannot be made if billed with HCPCS code 84153.

Noncovered Diagnosis Codes

PSA testing performed for indications other than those listed above will be considered not medically necessary or reasonable and will result in denial of coverage.

Any diagnoses other that those listed will be denied without additional documentation.

Sources of Information

1996 CPT Book, American Medical Association, p. 306
Laboratory and Diagnostic Tests, Fifth Edition, Lippincott, 1996
Other Carriers' Policies

Documentation Required

ICD-9 diagnosis codes are required on claim.

Medical records must clearly document the medical necessity for the test and the frequency of the test.

If documentation is requested for review, submit the following:


Comments

This policy is being adapted from the Carrier policy. It does not represent the sole opinion of the Intermediary/Medical Director. This policy was developed in consultation with the medical community via the Carrier Advisory Committee.

Date of Notice and Comments: April 3, 1996
Notice Period Date: October, 1996
Effective Date of Policy: November 1, 1996