LCD for Prostate Specific Antigen (PSA)

Transcription

1 LCD for Prostate Specific Antigen (PSA) Applicable CPT Code(s): Prostate Specific Antigen (PSA); Complexed (Direct Measurement) Prostate Specific Antigen (PSA); Total Prostate Specific Antigen (PSA); Free G0103 Prostate Cancer Screening; Prostate Specific Antigen Test (PSA) ICD-9 Codes that Support Medical Necessity: Code Description BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS) BLADDER NECK OBSTRUCTION CARCINOMA IN SITU OF PROSTATE ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA] GROSS HEMATURIA HEMATURIA, UNSPECIFIED HYPERTROPHY (BENIGN) OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS) HYPERTROPHY (BENIGN) OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT (LUTS) INCOMPLETE BLADDER EMPTYING MALIGNANT NEOPLASM OF BLADDER NECK 185 MALIGNANT NEOPLASM OF PROSTATE MICROSCOPIC HEMATURIA NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE NEOPLASM OF UNSPECIFIED NATURE OF OTHER GENITOURINARY ORGANS NOCTURIA NODULAR PROSTATE WITH URINARY OBSTRUCTION NODULAR PROSTATE WITHOUT URINARY OBSTRUCTION NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM

2 V10.46 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE PROSTATITIS UNSPECIFIED RETENTION OF URINE UNSPECIFIED V76.44* SCREENING FOR MALIGNANT NEOPLASMS OF THE PROSTATE SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRAPELVIC LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF INGUINAL REGION AND LOWER LIMB SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS SLOWING OF URINARY STREAM STRAINING ON URINATION UNSPECIFIED DISORDER OF PROSTATE URGENCY OF URINATION URINARY FREQUENCY URINARY HESITANCY URINARY INCONTINENCE UNSPECIFIED URINARY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED URINARY OBSTRUCTION, UNSPECIFIED *ICD-9-CM code V76.44 should only be reported with HCPCS code G0103 for a screening PSA test. It may not be used with other PSA tests (84152, 84153, or 84154).

3 NCD for Prostate Specific Antigen (PSA) Applicable CPT Code(s): Prostate Specific Antigen (PSA), total ICD-9 Codes that Support Medical Necessity: Code Description Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract Bladder neck obstruction Bone scan evidence of malignancy Bone scan evidence of malignancy Carcinoma in situ, prostate Elevated prostate specific antigen (PSA) Elevated prostate specific antigen (PSA) Gross hematuria Gross hematuria Hematuria, unspecified Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (LUTS) Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (LUTS) Incomplete bladder emptying Incomplete bladder emptying Malignant neoplasm of bladder neck 185 Malignant neoplasm of prostate Microscopic hematuria Microscopic hematuria Neoplasm of uncertain behavior of prostate Neoplasm of unspecified nature, other

4 genitourinary organs Nocturia Nocturia Nodular prostate with urinary obstruction Nodular prostate with urinary obstruction Nodular prostate without urinary obstruction Nodular prostate without urinary obstruction Non-specific (abnormal) findings on radiological and other examination of abdominal area, including retroperitoneum Non-specific (abnormal) findings on radiological and other examination of musculoskeletal system Non-specific (abnormal) findings on radiological and other examination of abdominal area, including retroperitoneum Non-specific (abnormal) findings on radiological and other examination of musculoskeletal system V10.46 Personal history of malignant neoplasm; prostate V10.46 Personal history of malignant neoplasm; prostate Retention of urine, unspecified Retention of urine, unspecified Secondary malignant neoplasm, bone and bone marrow Secondary malignant neoplasm, genital organs Secondary malignant neoplasm, intrapelvic lymph nodes Secondary malignant neoplasm, lymph nodes of inguinal region & lower limb Secondary malignant neoplasm, lymph nodes of multiple sites Slowing of urinary stream Slowing of urinary stream Straining on urination Straining on urination Unspecified disorder of prostate Unspecified disorder of prostate Unspecified prostatitis Unspecified prostatitis Urgency of urination Urgency of urination Urinary frequency Urinary frequency Urinary hesitancy

5 Urinary hesitancy Urinary incontinence, unspecified Urinary incontinence, unspecified , Urinary obstruction