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Medicare's new PSA coverage, revised CPT lab panels

From the February 2000 ACP–ASIM Observer, copyright 2000 by the American College of Physicians–American Society of Internal Medicine.

By Brett Baker


Q: Is it true that Medicare now covers prostate cancer screening?

A: Medicare began covering prostate cancer screening tests for beneficiaries that meet certain criteria on Jan. 1. Medicare covers an annual digital rectal examination (DRE) and a prostate-specific antigen (PSA) test for all male beneficiaries over 50 years old.

Although a screening DRE and PSA do not have to be performed and ordered respectively by the patient's attending or primary physician, Medicare does require that these services be performed/ordered by a physician who is "knowledgeable about the patient and responsible for explaining the results." Medicare's intent is to prohibit a physician from performing/ordering these services when he or she sees the patient infrequently or only once. The requirement is designed, however, to allow some flexibility. For example, a physician who is a member of the primary physician's group would be able to perform/order these services for the patient. Medicare will also pay for a DRE performed and a PSA test ordered by a physician assistant, clinical nurse specialist or certified nurse midwife if the same conditions are met.

In terms of frequency, Medicare will cover a screening DRE and PSA test if 11 months have passed since the month in which Medicare last paid for these services. If Medicare paid for a screening PSA test you ordered for a 65-year-old beneficiary on Feb. 15, 2000, for example, it will not pay for another screening PSA test for the same patient until Feb. 1, 2001. You do not have to wait a full 365 days to order another screening PSA test.

To reimburse physicians for its new coverage, Medicare has created two new HCFA Common Procedure Coding System (HCPCS) codes to report screening DRE and PSA tests.

•Digital rectal examination.
HCPCS code G0102, which covers DREs, pays $20.14, the same rate as CPT code 99211. (This rate represents the national average; your payment will vary slightly, depending on your geographic area.)

Medicare will pay separately for a DRE if it is the only service provided during an encounter. It will also pay for a DRE separately if it is furnished as part of a service that is otherwise not covered. For example, Medicare would pay separately for a DRE provided during the course of a preventive medicine service visit, such as a periodic preventive medicine evaluation for patients 65 years and over (CPT 99397), if the other criteria are met.

Because HCFA believes that a screening DRE would rarely be the only service furnished during a patient encounter, however, it bundles payment for DRE screening into payment for a covered evaluation and management service when the two services are provided to the same patient on the same day.

ACP–ASIM is working to get Medicare to pay separately for a screening DRE.

•Prostate-specific antigen testing.
HCPCS code G0103, which covers PSA testing, pays the same rate as CPT code 84153, PSA. (This rate will vary depending on your location.) Medicare does not appear to require a specific diagnosis code to justify a screening PSA.


Q:
How has "Current Procedural Terminology 2000" (CPT) changed organ- or disease-oriented laboratory panels?

A: "CPT 2000" has added new laboratory tests to existing laboratory panels and assigned these revised panels new code numbers. (In the past, CPT did not change panel numbers after adding or deleting codes.) CPT has also created a new renal function panel and deleted its thyroid panels.

CPT maintains organ- or disease-oriented laboratory panels as a convenient way for physicians to order tests. Typically, a single diagnosis code is sufficient to justify the medical necessity of using such a panel. Tests ordered outside of a panel or tests ordered in addition to a panel, however, must be justified separately. To bill a panel code, you must perform all tests included on each panel.

It is important to note that Medicare carriers will not process claims using the new CPT code numbers until April 1. Medicare will refrain from making any system changes during the first three months of the new year to make sure that its technology is prepared to address any technical problems caused by year 2000 issues. As a result, physicians must use the old CPT 1999 organ- or disease-specific panel codes to order and bill panels before April 1. Laboratories also are unable to bill the new panels, so you should make sure your independent laboratory is clear about which tests you want. If you find ordering or billing a combination of old and new panel codes confusing, you can order tests individually until carriers can accept the new panel codes.

Here is a summary of the changes to organ- or disease-oriented panels:

  • Calcium, CPT 82310, was added to the basic metabolic panel, CPT 80048. The former basic metabolic panel code, CPT 80049, was deleted. Here is the new panel:

    80048 Basic metabolic panel (formerly 80049)
    Calcium (82310)
    Carbon dioxide (bicarbonate) (82374)
    Chloride (82435)
    Creatinine (82565)
    Glucose (82947)
    Potassium (84132)
    Sodium (84295)
    Urea Nitrogen (BUN) (84520)

  • Transferase, alanine amino, CPT 84460, was added to the comprehensive metabolic panel, CPT 80053. The former comprehensive metabolic panel code, CPT 80054, was deleted. Here is the new panel:

    80053 Comprehensive metabolic panel (formerly 80054)
    Albumin (82040)
    Bilirubin, total (82247)
    Calcium (82310)
    Carbon dioxide (bicarbonate) (82374)
    Chloride (82435)
    Creatinine (82565)
    Glucose (82947)
    Phosphatase, alkaline (84075)
    Potassium (84132)
    Protein, total (84155)
    Sodium (84295)
    Transferase, alanine amino (ALT) (SGPT) (84460)
    Transferase, aspartate amino (AST) (SGOT) (84450)
    Urea Nitrogen (BUN) (84520)

  • A renal function panel, CPT 80069, has been added to treat patients with renal disease. Here is the new panel:

    80069 Renal function panel
    Albumin (82040)
    Calcium (82310)
    Carbon dioxide (bicarbonate) (82374)
    Chloride (82435)
    Creatinine (82565)
    Glucose (82947)
    Phosphorus inorganic (phosphate) (84100)
    Potassium (84132)
    Sodium (84295)
    Urea Nitrogen (BUN) (84520)

  • An acute hepatitis panel, CPT 80074, was added to CPT at the request of laboratories, pathologists and other clinicians. The hepatitis panel, CPT 80059, was deleted. The acute hepatitis panel reflects technological advances in hepatitis testing. Testing utility has improved as it is now possible to separate between the IgG and IgM antibodies. Here is the new panel:

    80074 Acute hepatitis panel
    Hepatitis A antibody (HAAb), IgM antibody (86709)
    Hepatitis B core antibody (HbcAb), IgM antibody (86705)
    Hepatitis B surface antigen (HbsAg) (87340)
    Hepatitis C antibody (86803)

  • Protein, total, CPT 84155, has been added to the Hepatic function panel, CPT 80058. The former hepatic function panel, CPT 80058, was deleted. Here is the new panel:

    80076 Hepatic function panel (formerly 80058)
    Albumin Bilirubin, total Bilirubin, direct Phosphatase, alkaline (84075)
    Protein, total (84155)
    Transferase, alanine amino (ALT) (SGPT) (84460)
    Transferase, aspartate amino (AST) (SGOT) (84450)

  • The thyroid panel codes, CPT 80091 and 80092, have been deleted from CPT 2000 as they no longer reflect modern testing standards. You should use the individual codes for the specific thyroid tests you order for patients.


Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441, or send an e-mail to bbaker@acponline.org.

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