Medicare Denied Psa Lab Test

[Paul H]

I am a SHIP (State Health Insurance Assistance Program) volunteer working on 2 cases where a claim for a PSA lab test was denied. One was diagnostic, and the other was preventive screening. In both cases the clients had signed an ABN (Advance Beneficiary Notice) agreeing to pay for the test (at a cost of about 4 times what Medicare would pay) if Medicare denied the claim. One has filed the first level of appeal, the other has filed the second level of appeal.

There is no question that Medicare should pay for the PSA test once every 12 months for men over 50.

I believe that the denials are a result of coding errors by the ordering physician on the lab order. The medical offices have not been particularly helpful in resolving the problem.

The denials may be in part due to the complexity of the ICD-10 CM coding system that that took effect in October 2015.

I am considering advising clients not to sign ABN's in order to have coding and payment issues resolved before the tests are conducted.

Does anyone have any thoughts or relevant experiences?

 

[MBSC]

It is difficult to provide an answer without knowing the procedure code and diagnosis code billed and the messages on the MSN. It would be helpful if you could post that information. A common reason the preventive PSA test is denied is billing diagnostic CPT 84153 instead of preventive HCPCS G0103.

 

[Paul H]

It is difficult to provide an answer without knowing the procedure code and diagnosis code billed and the messages on the MSN. It would be helpful if you could post that information. A common reason the preventive PSA test is denied is billing diagnostic CPT 84153 instead of preventive HCPCS G0103.

#1 CPT 84153, ICD-10, Z00.00 I don't have the information from the MSN This lab test was ordered for a routine physical exam.

#2 CPT 84153, ICD-10, R93.8 The MSN included the notes: "Our records show that you were informed in writing, before receiving the service, that Medicare would not pay. You are liable for this charge. if you do not agree with this statement, you may ask for a review." and "The information provided does not support the need for this service or item."

This lab test was ordered after an abnormal X-ray of the wrist/hand. According to NCD 190.31, R93.8 is not covered by Medicare, however, R93.6, "Abnormal findings on diagnostic imaging of limbs is a covered code for PSA by Medicare.

 

[MBSC]

#1: A preventive PSA test should be billed with HCPCS G0103 and Dx Z12.5.

Reference: https://www.cms.gov/Medicare/Preven...wnloads/MPS-QuickReferenceChart-1TextOnly.pdf

#2: I agree. R93.6 is a covered code and includes wrist/hand but excludes skin/tissue (R93.8). I know you said the provider was being difficult but the patient needs to verify the diagnosis was coded correctly.

 

[JoeFriday]

#1: A preventive PSA test should be billed with HCPCS G0103 and Dx Z12.5.

Reference: https://www.cms.gov/Medicare/Preven...wnloads/MPS-QuickReferenceChart-1TextOnly.pdf

#2: I agree. R93.6 is a covered code and includes wrist/hand but excludes skin/tissue (R93.8). I know you said the provider was being difficult but the patient needs to verify the diagnosis was coded correctly.

I just received an MSN for the blood work that my personal physician ordered as part of my annual physical. Under "Service Provided & Billing Code" there is an entry for "Prostate cancer screening: prostate specific antigen test (psa) (G0103)". Under "Service Approved" is "NO". It had been more than 12 months since my last psa test. I called 1-800-MEDICARE for an explanation, they couldn't provide one after 20 min. on the phone. I have called the SHIP number listed and left my information on their recording prompt but haven't heard back from them. All of the other blood test work on the MSN was approved and paid by Medicare. Any suggestions on how I should go about trying to resolve this will be appreciated. Thank you.

 

[MBSC]

I just received an MSN for the blood work that my personal physician ordered as part of my annual physical. Under "Service Provided & Billing Code" there is an entry for "Prostate cancer screening: prostate specific antigen test (psa) (G0103)". Under "Service Approved" is "NO". It had been more than 12 months since my last psa test. I called 1-800-MEDICARE for an explanation, they couldn't provide one after 20 min. on the phone. I have called the SHIP number listed and left my information on their recording prompt but haven't heard back from them. All of the other blood test work on the MSN was approved and paid by Medicare. Any suggestions on how I should go about trying to resolve this will be appreciated. Thank you.

Contact your provider's billing office and ask for the diagnosis code that was billed with G0103. These issues usually occur when the diagnosis Z00.00 for the annual physical charge is copied to G0103. If this is the case, the provider should submit a corrected claim with an approved diagnosis code for G0103. Good luck.