Proper Billing Procedure for PSA Screening

Medicare Billing Guidelines

The Centers for Medicare and Medicaid Services recommends using HCPCS code G0103 for Medicare patients receiving a screening PSA test, and annual PSA screening is covered for men age 50 and older with no cost-sharing for the patient 1
Medicare patients with higher risk factors, such as African American race or family history, should have these risk factors documented in the medical record to support earlier screening at age 45 1
The American Medical Association recommends including appropriate ICD-10 diagnosis code Z12.5 to indicate the preventive nature of the service 1

The American Academy of Family Physicians suggests using CPT code 84153 for commercial insurance patients, and including appropriate ICD-10 diagnosis code Z12.5 1
For patients with family history of prostate cancer, the American College of Physicians recommends considering using additional code Z80.42 to support medical necessity for earlier or more frequent screening 2

The American Urological Association recommends documenting that the patient was informed about the benefits and potential harms of PSA screening prior to ordering the test, with a strength of evidence rated as high 3
For average-risk men, annual screening typically begins at age 50 if life expectancy is at least 10 years, based on moderate-strength evidence 1
The National Comprehensive Cancer Network recommends clearly documenting the medical necessity for the screening test in the patient's chart, with a strength of evidence rated as high 3

The American Medical Association warns against using diagnostic codes for symptoms when the test is truly for screening purposes, as this may result in incorrect patient cost-sharing, based on low-strength evidence 2
The Centers for Medicare and Medicaid Services advises against using diagnostic PSA codes for screening purposes as this may result in inappropriate patient billing, with a strength of evidence rated as high 1

The American Urological Association recommends documenting both reasons but billing with the primary indication that prompted the test if a patient has both screening and diagnostic indications, based on moderate-strength evidence 1
For patients on active surveillance for previously diagnosed prostate cancer, the National Comprehensive Cancer Network suggests using diagnostic codes rather than screening codes, with a strength of evidence rated as high 3