National Coverage Determination (NCD)

Prostate Cancer Screening Tests

210.1

Expand All | Collapse All

Tracking Information

Publication Number
100-3
Manual Section Number
210.1
Manual Section Title
Prostate Cancer Screening Tests
Version Number
2
Effective Date of this Version
06/19/2006
Implementation Date
06/19/2006

Description Information

Benefit Category
Prostate Cancer Screening Tests


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Indications and Limitations of Coverage

CIM 50-55

Covered

A. General

Section 4103 of the Balanced Budget Act of 1997 provides for coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations. Medicare will cover prostate cancer screening tests/procedures for the early detection of prostate cancer. Coverage of prostate cancer screening tests includes the following procedures furnished to an individual for the early detection of prostate cancer:

  • Screening digital rectal examination; and
  • Screening prostate specific antigen blood test

B. Screening Digital Rectal Examinations

Screening digital rectal examinations are covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered screening digital rectal examination was performed). Screening digital rectal examination means 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 (as defined in §1861(r)(1) of the Act), or by a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife (as defined in §1861(aa) and §1861(gg) of the Act) who is authorized under State law to perform the examination, fully knowledgeable about the beneficiary's medical condition, and would be responsible for using the results of any examination performed in the overall management of the beneficiary's specific medical problem.

C. Screening Prostate Specific Antigen Tests

Screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered screening prostate specific antigen test was performed). Screening prostate specific antigen tests (PSA) means a test to detect the marker for adenocarcinoma of prostate. PSA is a reliable immunocytochemical marker for primary and metastatic adenocarcinoma of prostate. This screening must be ordered by the beneficiary's physician or by the beneficiary's physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife (the term "attending physician" is defined in §1861(r)(1) of the Act to mean a doctor of medicine or osteopathy and the terms "physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife" are defined in §1861(aa) and §1861(gg) of the Act) who is fully knowledgeable about the beneficiary's medical condition, and who would be responsible for using the results of any examination (test) performed in the overall management of the beneficiary's specific medical problem.

Transmittal Information

Transmittal Number
48
Revision History

04/1999 - Provided coverage for certain prostate cancer screening tests as mandated by section 4103 of the BBA of 1997. Effective date 01/01/2000. (TN 109).  Conforming regulations found at 42 CFR  §410.39 (http://www.gpo.gov/nara/cfr/index.html)

03/2006 - Delete coding information. Effective/Implementation date: 06/19/2006. (TN 48) (CR4278)

01/2013 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. These updates do not expand, restrict, or alter existing coverage policy. Implementation date: 04/01/2013 Effective date: 10/1/2015. (TN 1165) (CR 8109)

05/2014 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. These updates do not expand, restrict, or alter existing coverage policy. Implementation date: 10/06/2014 Effective date: 10/1/2015. (TN 1388) (TN 1388) (CR 8691)

Additional Information

Other Versions
Title Version Effective Between
Prostate Cancer Screening Tests 2 06/19/2006 - N/A You are here
Prostate Cancer Screening Tests 1 01/01/2000 - 06/19/2006 View
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. 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.