Coding Tips for Prostate Cancer Screening, Diagnosis, and Treatments

Written by Amy Wagner, MEd, CHA, CPC, ICDCT-CM

Edited by Joanne Byron, BS, LPN, CCA, CHA, CHCO, OHCC, CMDP, ICDCT-CM/PCS

According to the Cancer Research Institute, prostate cancer is the second most common male cancer in the world.  It affects roughly 1.3 million people and kills more than 360,000 people each year, which represents about 4% of all cancer deaths worldwide.   In its early stages, prostate cancer is highly treatable, with five-year survival rates close to 100%. Once prostate cancer has metastasized, however, the 5-year survival rate falls to less than 30%, highlighting a significant need for more effective treatment of advanced stage disease.

Because prostate cancer is highly curable when detected in the early stages, Medicare (and most commercial payers) cover the cost of annual screening for the disease in male beneficiaries over the age of 50.  There are two common tests used to screen for prostate cancer, the digital rectal exam (DRE) and the Prostate specific antigen (PSA) blood test.   Medicare requires HCPCS codes to report these tests.

G0102   Prostate cancer screening; digital rectal examination

• The provider performs a digital exam to detect abnormalities of the prostate.
  • *This test is not billed separately when performed as part of an office visit being billed with an Evaluation & Management code. 
• Medicare defines a screening DRE as a clinical examination of an individual’s prostate for nodules or other abnormalities of the prostate. This screening must be performed by a doctor of medicine or osteopathy, physician assistant, nurse practitioner, clinical nurse specialist, or by a certified nurse midwife who is authorized under State law to perform the examination, fully knowledgeable about the beneficiary's medical condition, and would be responsible for explaining the results of the examination to the beneficiary.

G0103   Prostate cancer screening; prostate specific antigen test (psa)

• Medicare defines a screening PSA as a test that measures the level of prostate specific antigen in an individual’s blood. This screening must be ordered by the beneficiary’s physician (doctor of medicine or osteopathy) or by the beneficiary’s physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife who is fully knowledgeable about the beneficiary's medical condition, and would be responsible for explaining the results of the test to the beneficiary.

Record a Pertinent History During the Visit

When ordering a PSA test, there are variables to consider and record which can cause elevated or lower PSA levels. If your practice provides wellness exams and/or orders prostate screening tests, it is highly recommended to modify your patient questionnaire to gather specific information for the ordering provider’s consideration.

Factors that might raise PSA levels should be included in the History of Present Illness Documentation, when the test is ordered, such as:

• Current Diagnosis of BPH: Conditions such as benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate that affects many men as they grow older, can raise PSA levels.
• Older age: PSA levels normally go up slowly as you get older, even if you have no prostate abnormality.
• Prostatitis: This is an infection or inflammation of the prostate gland, which can raise PSA levels.
• Ejaculation: This can make the PSA go up for a short time. This is why some doctors suggest that men abstain from ejaculation for a day or two before testing.
• Riding a bicycle: Some studies have suggested that cycling may raise PSA levels for a short time (possibly because the seat puts pressure on the prostate), although not all studies have found this.
• Certain urologic procedures: Some procedures done in a doctor’s office that affect the prostate, such as a prostate biopsy or cystoscopy, can raise PSA levels for a short time. Some studies have suggested that a digital rectal exam (DRE) might raise PSA levels slightly, although other studies have not found this. Still, if both a PSA test and a DRE are being done during a doctor visit, some doctors advise having the blood drawn for the PSA before having the DRE, just in case.
• Certain medicines: Taking male hormones like testosterone (or other medicines that raise testosterone levels) may cause a rise in PSA.
• Certain urologic procedures: Some procedures done in a doctor’s office that affect the prostate, such as a prostate biopsy or cystoscopy, can raise PSA levels for a short time. Some studies have suggested that a digital rectal exam (DRE) might raise PSA levels slightly, although other studies have not found this. Still, if both a PSA test and a DRE are being done during a doctor visit, some doctors advise having the blood drawn for the PSA before having the DRE, just in case.
• Certain medicines: Taking male hormones like testosterone (or other medicines that raise testosterone levels) may cause a rise in PSA.

Factors which might lower PSA level – even if the man has prostate cancer:

• 5-alpha reductase inhibitors: Certain drugs used to treat BPH or urinary symptoms, such as finasteride (Proscar or Propecia) or dutasteride (Avodart), can lower PSA levels. These drugs can also affect prostate cancer risk (discussed in Can Prostate Cancer Be Prevented?). Tell your doctor if you are taking one of these medicines. Because they can lower PSA levels, the doctor might need to adjust for this.
• Herbal mixtures: Some mixtures that are sold as dietary supplements might mask a high PSA level. This is why it’s important to let your doctor know if you are taking any type of supplement, even ones that are not necessarily meant for prostate health. Saw palmetto (an herb used by some men to treat BPH) does not seem to affect PSA.
• Certain other medicines: Some research has suggested that long-term use of certain medicines, such as aspirin, statins (cholesterol-lowering drugs), and thiazide diuretics (such as hydrochlorothiazide) might lower PSA levels. More research is needed to confirm these findings, according to the American Cancer Society.

Medicare’s Coverage Depends upon Eligibility & Frequency

• Medicare provides coverage of an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male beneficiaries age 50 and older (coverage begins the day after the beneficiary's 50th birthday), if at least 11 months have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed for the early detection of prostate cancer.

• When calculating frequency, to determine the 11-month period, the count starts beginning with the month after the month in which a previous test/procedure was performed.
  • EXAMPLE: The beneficiary received a screening PSA test in January 2006. The count starts beginning February 2006. The beneficiary is eligible to receive another screening PSA test in January 2007 (the month after 11 months have passed).

Outside of the annual screening, if the patient presents with symptoms leading the provider to screen for prostate cancer, code the associated symptoms.

84152    Prostate specific antigen (PSA); complexed (direct measurement)

84153    Prostate specific antigen (PSA); total

84154    Prostate specific antigen (PSA); free

The ICD-10-CM code to use for annual screening services is Z12.5, Encounter for screening for malignant neoplasm of prostate.

• Codes in the Z12 category have a “Use additional code” instruction if there is family history of the disease. Z80.42, Family history of malignant neoplasm of prostate would also be used if there is a familial history of the disease.

Benign Conditions of the Prostate

Screening may detect nodules or other abnormalities of the prostate. Benign prostatic hyperplasia or hypertrophy, enlarged prostate, or nodular prostate are common conditions code in category N40. The 4^th digit is used to describe the condition and/or the presence of associated lower urinary tract symptoms as follows:

N40.0        Benign prostatic hyperplasia without lower urinary tract symptoms

N40.1        Benign prostatic hyperplasia with lower urinary tract symptoms

N40.2        Nodular prostate without lower urinary tract symptoms

N40.3        Nodular prostate with lower urinary tract symptoms

When coding N40.1 or N40.3, there is a “Use additional code” instruction for associated symptoms as follows:

R39.14       Incomplete bladder emptying 

R35.1         Nocturia

R39.16       Straining on urination

R35.0         Urinary frequency

R39.11       Urinary hesitancy

N39.4-        Urinary incontinence

N13.8         Urinary obstruction

R33.8         Urinary retention

R39.15       Urinary urgency

R39.12       Weak urinary stream

If the biopsy does indicate a cancer diagnosis, code C61 is used. C61 has a “Use additional code” instruction to identify the following:

Referencing the ICD-10-CM Table of Neoplasms, the following codes are also listed with prostate neoplasms:

• D29.1 has an Excludes1 Note for conditions in category N40.-, Enlarged prostate

CPT® Coding: Additional Testing and Treatments for Prostate Cancer

An abnormal screening for the prostate may require further testing such as biopsy.

Treatment

• Conventional treatments for early-stage prostate cancer include surgery and radiation.
• Hormonal therapy, which can reduce levels of the male hormones (androgens like testosterone) that lead to tumor growth, is also used to treat early-stage tumors.
• Immunotherapy is class of treatments that take advantage of a person’s own immune system to help kill cancer cells. There are currently two FDA-approved immunotherapy options for prostate cancer.
• Cancer Vaccines - Sipuleucel-T (Provenge®): a vaccine composed of patients’ own immune cells, which have been stimulated to target the PAP (prostatic acid phosphatase) protein highly expressed on prostate cancers; approved for subsets of patients with advanced prostate cancer.

When the condition is advanced or is diagnosed as metastatic prostate cancer, chemotherapy is also a treatment option.

Radiation treatments are primarily used to treat localized prostate cancer. There are different types of radiation therapy including brachytherapy, radionuclide treatments and external beam radiation therapy (EBRT). The Radiation / Radiation Oncology section of the CPT book will guide the coder to the appropriate treatments in categories in these categories.  The following procedures may be appropriate depending on the therapy:

Treatment of prostate cancer may also require surgical removal of the prostate. CPT codes for prostatectomy include:

These codes require careful review of the surgical documentation to determine whether the surgery was partial or total, open or laparoscopic, or included other procedures.  Because erectile dysfunction is a common side effect of prostate disease or treatments, a code from category N52 may be appropriate:

N52.1        Erectile dysfunction due to disease classified elsewhere 

                  Code first underlying disease

N52.31      Erectile dysfunction following radical prostatectomy

N52.35      Erectile dysfunction following radiation therapy

N52.36      Erectile dysfunction following interstitial seed therapy

N52.37      Erectile dysfunction following prostate ablative therapy

Personal History

Once the patient is found to be cancer-free, a code of Z85.46, Personal history of malignant neoplasm of prostate is reported.  When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

• Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.

Current malignancy versus personal history of malignancy

• When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
• When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

Subcategories Z85.0 – Z85.7 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Codes from subcategory Z85.8-, may be assigned for the former site(s) of either a primary or secondary malignancy included in this subcategory.

Disclaimer

CPT® codes are used as reference only for educational purposes and copyright held by the American Medical Association. The information in this article is not intended as consulting or legal advice.  Please consult payer guidelines for coding and coverage information.

References

• American Cancer Society
• Cancer Research Institute
• ICD-10-CM Coding Guidelines
• MLN Matters Number: SE0709 Revised
• NCD 210.1 Prostate Cancer Screening Tests