Coding and Billing for Diagnosis and Treatment of Prostate Cancer

Introduction

Today, cancer of the prostate has become an everyday problem in most urological practices. In this chapter we will review the coding and billing of the various services provided by urologists for this clinical problem. The correct use of diagnostic and procedural codes will be presented so that entitled reimbursements may be collected for diagnostic and therapeutic services.

The International Classification of Disease, 9th and 10th revisions, Clinical Modification (ICD-9-CM and ICD-10-CM), based on the official version of the World Health Organization’s ICD-9 and ICD-10 manual, will be used for documenting the specific diagnostic codes. ICD-10-CM code set will begin October 1, 2015. Before that date one should only use the ICD-9-CM code set.

The 2014 and 2015 CPT – Current Procedural Terminology will be used to document diagnostic and surgical procedures related to cancer of the prostate. The CPT Assistant as well as the Internet Only Manual (IOM) will also be used to help maintain and ensure compliant and accurate coding.

Diagnoses

ICD-9 code 185 and ICD-10 code C61 are the diagnostic codes used for malignant neoplasm of the prostate. Note that ICD-9 code 185 and ICD-10 code C61 contain three characters. 185 is all numeric and C61 is alpha-numeric. Most ICD-9 codes are numeric and all ICD-10 codes are alpha-numeric. Codes 185 and C61 include the various histological malignant tumors of the prostate namely, the common adenocarcinoma, transitional cell tumors, squamous cell tumors, and prostatic sarcoma. Other diagnoses often associated with neoplasms of the prostate include carcinoma in situ of the prostate, high grade prostatic intraepithelial neoplasm, high grade PIN, diagnostic codes 233.4 for ICD-9 and D07.5 for ICD-10, dysplasia of the prostate, PIN grades 1 and 2, diagnostic codes 602.3 for ICD-9 and N42.3 for ICD-10 ( Table 63.1 ). ICD-9 code 790.93 and ICD-10 code R07.2 indicate an elevated prostate-specific antigen (PSA). A PSA level is considered elevated when determined as elevated by the attending urologist not only by the determined level itself. For example, an elevation of PSA above four may or may not represent a true elevation. However, a PSA level of 0.5 several months after a radical prostatectomy would represent an elevation. In either example the diagnosis would be 790.93, elevation of PSA.

Other diagnostic codes associated with carcinoma of the prostate are ICD-9 code 187.8 and ICD-10 code C63.7, malignant neoplasm of seminal vesicles, ICD-9 code 198.82 and ICD-10 code C79.82, secondary neoplasm of the seminal vesicles.

Prostate cancer screening

In 2000, Medicare established specific coding guidelines and reimbursement fees for an annual prostate cancer screening. Two Healthcare Common Procedure Coding System (HCPCS) codes have been assigned for this screening: (1) G0102 – prostate cancer screening; digital rectal examination and (2) G0103 – prostate cancer screening; prostate-specific antigen test. These HCPCS codes are payable for yearly screening (performed at least 11 1/2 months apart) in males 50 years of age and older with Medicare insurance and with no historical, clinical, or laboratory evidence of carcinoma of the prostate. The ICD-9 screening diagnoses for carcinoma of the prostate are V76.44 for ICD-9 and Z12.5 for ICD-10.

Reimbursements for G0102 and G0103 will be similar to payment for CPT E/M code 99211 and for G0103 similar to payment for 84153, PSAand total ( Table 63.2 ).

Table 63.3 shows diagnoses supporting medical necessity for PSA determinations.

Office consultative services (urological consultations)

Often the urologist is requested by another physician or health care provider, (nonphysician provider, NPP), for his/her opinion (consultation) concerning an elevated PSA (790.93) or an abnormal rectal examination with a nodule (239.5). In 2010, Medicare deleted from their code set all office and hospital consultation codes, namely, 99241–99245 and 99251–99255, and replaced the office consult codes with 99201–99205, new patient office visits and hospital consultation codes with 99221–99223, initial hospital visits. Note that some commercial carriers continue to utilize the previous consultation codes 99241–99255, and one should check with their nonMedicare carriers as to which codes they prefer when billing for a urological consultation. The documentation of a consultation placed in the medical records should include a request from the primary care physician for the consultation or a statement thereof, as well as a consultation letter (a report) to the requesting physician with recommendations concerning the diagnosis and further care.

After an initial examination, a urologist may accept the patient for complete care. This constitutes a transfer of care from the requesting physician to the urologist. Contrary to the opinion of some carriers this initial encounter by the urologist does in fact constitute a consultation and a consultation code should be billed in this clinical scenario.