Local Coverage Article Billing and Coding

Billing and Coding: Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis

A56609

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Contractor Information

Article Information

General Information

Article ID
A56609
Article Title
Billing and Coding: Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis
Article Type
Billing and Coding
Original Effective Date
12/01/2019
Revision Effective Date
01/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

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Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed.

 

Coding Information

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

The CPT codes in Group 1 are considered medically necessary.

%fPSA should be billed using codes 84153 and 84154.

PHI should be billed using codes 84153, 84154 and 86316.

EPI should be billed using code 0005U.

Group 1 Codes
CodeDescription
81539 ONCOLOGY (HIGH-GRADE PROSTATE CANCER), BIOCHEMICAL ASSAY OF FOUR PROTEINS (TOTAL PSA, FREE PSA, INTACT PSA, AND HUMAN KALLIKREIN-2 [HK2]), UTILIZING PLASMA OR SERUM, PROGNOSTIC ALGORITHM REPORTED AS A PROBABILITY SCORE
84153 PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL
84154 PROSTATE SPECIFIC ANTIGEN (PSA); FREE
86316 IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH
0005U ONCOLOGY (PROSTATE) GENE EXPRESSION PROFILE BY REAL-TIME RT-PCR OF 3 GENES (ERG, PCA3, AND SPDEF), URINE, ALGORITHM REPORTED AS RISK SCORE

Group 2

Group 2 Paragraph

The CPT codes in Group 2 are not considered medically necessary.

81479 is not considered medically necessary when used for SelectMDx, MiPS

 

Group 2 Codes
CodeDescription
81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE

CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes
CodeDescription
R97.20 Elevated prostate specific antigen [PSA]

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
XX000 Not Applicable

Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2021 R2

Due to the annual CPT/HCPCS update CPT codes 84153 and 84154 descriptions were changed in Group 1.

12/01/2019 R1

Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.

This article was converted to a Billing and Coding Article type.

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/27/2021 01/01/2021 - N/A Currently in Effect You are here
10/02/2019 12/01/2019 - 12/31/2020 Superseded View
05/30/2019 12/01/2019 - N/A Superseded View

Keywords

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