Billing and Coding: Prostate Cancer Detection with IsoPSA

This article gives guidance for billing, coding and other guidelines in
relation to local coverage policy **** IsoPSATM.

**General Guidelines for Claims submitted to Part A or Part B MAC**

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. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.

**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines:**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary, and they do have an ABN signed by the
beneficiary on file. Modifier GA applies only when services will be denied
under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9),
1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part
A MAC systems will automatically deny services billed with modifier GA. An
ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that
he/she accepts responsibility for payment. The -GA modifier may also be used
on assigned claims when a patient refuses to sign the ABN and the latter is
properly witnessed. For claims submitted to the Part A MAC, occurrence code 32
and the date of the ABN is required.

Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.

The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.



Coding Instructions:

To bill for IsoPSA use CPT 0359U.

Note: As this test is not a molecular pathology test that would fall under the
MolDx program labs are not required to submit a technical assessment for this
test and a DEX Z-codeTM is not required on the claim.

Documentation Requirements:

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of PSA testing
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
  * Risk factors for prostate biopsy