CPT – G0102 & G0103 -Prostate cancer screening

CPT and Diagnosis information

Prostate cancer is the second leading cause of cancer-related death in men and about 62 percent of all diagnosed prostate cancers are found in men age 65 or older.1 Medicare provides coverage of prostate cancer screening  tests/procedures for the early detection of prostate cancer. The two most common screenings used by physicians to detect prostate cancer are the screening Prostate Specific Antigen (PSA) blood test and the screening Digital Rectal Examination (DRE).

Prostate specific antigen is a protein the cells of the prostate gland produce and release into the blood. The screening PSA blood test measures the level of prostate specific antigen in an individual’s blood. The Food and Drug Administration (FDA) approved the use of the PSA blood test along with a DRE to help detect prostate cancer in men age 50 and older. The FDA has also approved the PSA blood test to monitor patients with a history of prostate cancer to determine if the cancer recurs.2

The Digital Rectal Examination (DRE)

The screening DRE is a clinical examination for checking the health of an individual’s prostate gland. The  prostate is checked for size and any irregularities or abnormalities of the prostate gland.

Coverage Information

Medicare provides coverage of an annual preventive prostate cancer screening PSA blood 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 PSA test or DRE was performed for the early detection of prostate cancer.

Diagnosis Requirements

Medicare providers must submit claims with correct diagnosis for prostate cancer screening DREs and screening PSA blood tests using screening (“V”) code V76.44 (Special Screening for Malignant Neoplasms, Prostate). For further guidance, contact your Medicare Contractor.

Prostate Cancer Screening Coverage for Eligible Medicare Patients


Provider Action Needed 


This article conveys no new policy that requires provider action. The article is for informational purposes only and serves as a reminder that Medicare provides coverage of certain prostate cancer screening tests subject to certain coverage, frequency and payment limitations.


Introduction 


Effective for services furnished on or after January 1, 2000, Medicare Part B covers annual preventive prostate cancer screening tests/procedures for the early detection of prostate cancer. The information in this Special Edition MLN Matters article reminds health care professionals about the coverage criteria, eligibility requirements, frequency parameters and correct coding when submitting claims for prostate cancer screening services so that you can talk with your Medicare patients about this preventive benefit and file claims properly for the screening service.


The Screening Services Defined 


A. Screening Digital Rectal Examination (DRE) 


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 patient’s medical condition and would be responsible for explaining the results of the examination to the patient.


B. Screening Prostate Specific Antigen (PSA) Tests 


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 patient’s physician (doctor of medicine or osteopathy) or by the patient’s physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife who is fully knowledgeable about the patient’s medical condition and would be responsible for explaining the results of the test to the patient.


Coverage Information 


Medicare Provides Coverage of the Following Prostate Cancer Screening Tests


Screening digital rectal examination (DRE)


Screening prostate specific antigen (PSA) blood test


Eligibility & Frequency 


Medicare provides coverage of an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male patients age 50 and older (coverage begins the day after the patient’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.




Calculating Frequency 


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 patient received a screening PSA test in January 2006. The count starts beginning February 2006. The patient is eligible to receive another screening PSA test in January 2007 (the month after 11 months have passed).


Deductible & Coinsurance/Co-payment


The screening PSA blood test is a lab test for which neither the deductible nor coinsurance/co-payment apply


The screening DRE the Medicare Part B deductible and coinsurance/co-payment apply

The following are examples of situations when Medicare may deny coverage of the annual preventive prostate cancer screening services:

 The beneficiary is not at least age 50 (coverage begins the day after the beneficiary’s 50th birthday).

The beneficiary has received a covered PSA/DRE during the past year.

The beneficiary received a covered E/M service on the same day as the DRE from the physician (carrier/AB MAC only).