Revenue Cycle

Prostate Health Month: Show your awareness

Coding Educator, September 21, 2009

 

By Peggy S. Blue, MPH, CPC, CCS-P
 
Most people are aware of the very successful educational campaign of the pink ribbon signifying breast cancer awareness. But do you know what a light blue ribbon represents? A light blue ribbon is the symbol for prostate cancer. The American Foundation for Urologic Disease (AFUD) has designated September as Prostate Health Month.
 
The prostate is a gland that is part of the male reproductive system. It is located in front of the rectum and just below the bladder. The main function of the prostate is to produce fluid for semen, which transports sperm. Approximately the size of a walnut, the doughnut-shaped prostate wraps around the urethra, the tube through which urine exits the body.
 
Prostate problems are very common. Eight in 10 men will eventually develop an enlarged prostate and one in 10 men will develop prostate cancer. Prostate cancer is the second most common type of cancer among men in this country, following skin cancer. Approximately 37,000 American men die annually from prostate cancer—often because they were diagnosed too late. Despite the prevalence of prostate disease, many men lack awareness about prostate health and many are also reluctant to seek treatment.
 
Physicians can check for prostate cancer before any symptoms have occurred. During an office visit, the physician may perform a digital rectal exam (DRE) and/or draw a blood specimen, usually from the patient’s arm, to test for a prostate-specific antigen (PSA).
  • Coding Tip: Medicare requires coders to report prostate cancer screening DREs and screening PSA blood tests using screening diagnosis code V76.44 (special screening for malignant neoplasms, prostate).
Fear of the digital rectal exam is probably one of the biggest reasons that men avoid important screening services for prostate cancer. The bottom line (get it?) is that it only takes a few seconds. It may be somewhat uncomfortable, but it’s not very painful. The doctor inserts a lubricated, gloved finger into the rectum and feels the prostate through the rectal wall to check for hard or lumpy areas. (The AFUD also notes the irony of having the month of September declared as both Prostate Health Month and National Chicken Month.)
  • Coding Tip: The digital rectal exam for prostate cancer screening is represented by code G0102. Code G0102 is bundled into payment with a separately payable evaluation and management (E/M) service when the physician performs both on the same day. When the physician performs code G0102 by itself or with a noncovered preventative E/M, then it is separately payable by Medicare.
The physician may also order a blood test to check a patient’s PSA level. PSA levels above a certain level—usually 4 nanograms per mL—is considered abnormal.
  • Coding Tip: Report a screening PSA test with code G0103. A laboratory performs and bills the test. Report the physician’s collection of the specimen by venipuncture with code 36415.
The DRE and PSA test can detect a problem in the prostate. However, they can't show whether the problem is cancer or a less serious condition. When a patient has abnormal test results, the physician may suggest other tests to make a diagnosis. For example, the physician may include other tests (e.g., a urine test to check for blood or infection). Additionally, the physician may order other procedures (e.g., a transrectal ultrasound or ultrasound guidance with a biopsy).
 
When performing a transrectal ultrasound, physicians insert a probe into the rectum to check for abnormalities. The probe sends out sound waves, which bounce off the prostate. A computer uses the echoes to create a sonogram.
  • Coding Tip: Procedure code 76872 represents a transrectal ultrasound. Coders may break the procedure down by the professional component (with modifier -26) and technical component (with modifier -TC). Remember to report the appropriate modifier if you are not billing for the global service.
The physician may also perform a prostate biopsy with the aid of ultrasound guidance.
  • Coding Tip: CPT code 76942 (ultrasonic guidance for needle placement) describes an ultrasound used to localize a mass or region to be biopsied with a needle, and to guide the needle into the mass or region. Again, modifier -26 or -TC would apply when coders bill for only one component of the imaging service.
The purpose of the biopsy is to remove tissue to look for cancer cells. It's the only definitive way to diagnose prostate cancer. During the procedure, the physician inserts needles through the rectum into the prostate and removes small tissue samples from several areas. A pathologist then checks the tissue samples for cancer cells.
  • Coding Tip: The biopsy code will depend on how the physician performed the biopsy. Use code 55700 to describe a needle biopsy of the prostate.
Editor's note: Peggy S. Blue, MPH, CPC, CCS-P, is a regulatory specialist for HCPro, Inc. You can e-mail her at pblue@hcpro.com.

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