LCD for Prostate Specific Antigen (PSA) Applicable CPT Code(s): 84152 Prostate Specific Antigen (PSA); Complexed (Direct Measurement) 84153 Prostate Specific Antigen (PSA); Total 84154 Prostate Specific Antigen (PSA); Free G0103 Prostate Cancer Screening; Prostate Specific Antigen Test (PSA) ICD-9 Codes that Support Medical Necessity: Code Description 600.21 BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS) 596.0 BLADDER NECK OBSTRUCTION 233.4 CARCINOMA IN SITU OF PROSTATE 790.93 ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA] 599.71 GROSS HEMATURIA 599.70 HEMATURIA, UNSPECIFIED 600.01 HYPERTROPHY (BENIGN) OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS) 600.00 HYPERTROPHY (BENIGN) OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT (LUTS) 788.21 INCOMPLETE BLADDER EMPTYING 188.5 MALIGNANT NEOPLASM OF BLADDER NECK 185 MALIGNANT NEOPLASM OF PROSTATE 599.72 MICROSCOPIC HEMATURIA 236.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE 239.5 NEOPLASM OF UNSPECIFIED NATURE OF OTHER GENITOURINARY ORGANS 788.43 NOCTURIA 600.11 NODULAR PROSTATE WITH URINARY OBSTRUCTION 600.10 NODULAR PROSTATE WITHOUT URINARY OBSTRUCTION 793.6 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM
V10.46 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE 601.9 PROSTATITIS UNSPECIFIED 788.20 RETENTION OF URINE UNSPECIFIED V76.44* SCREENING FOR MALIGNANT NEOPLASMS OF THE PROSTATE 196.6 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRAPELVIC LYMPH NODES 196.5 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 196.8 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES 198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW 198.82 SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS 788.62 SLOWING OF URINARY STREAM 788.65 STRAINING ON URINATION 602.9 UNSPECIFIED DISORDER OF PROSTATE 788.63 URGENCY OF URINATION 788.41 URINARY FREQUENCY 788.64 URINARY HESITANCY 788.30 URINARY INCONTINENCE UNSPECIFIED 599.69 URINARY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED 599.60 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).
NCD for Prostate Specific Antigen (PSA) Applicable CPT Code(s): 84153 Prostate Specific Antigen (PSA), total ICD-9 Codes that Support Medical Necessity: Code Description 600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract 600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract 596.0 Bladder neck obstruction 794.9 Bone scan evidence of malignancy 794.9 Bone scan evidence of malignancy 233.4 Carcinoma in situ, prostate 790.93 Elevated prostate specific antigen (PSA) 790.93 Elevated prostate specific antigen (PSA) 599.71 Gross hematuria 599.71 Gross hematuria 599.70 Hematuria, unspecified 600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract 600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract 600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (LUTS) 600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract (LUTS) 788.21 Incomplete bladder emptying 788.21 Incomplete bladder emptying 188.5 Malignant neoplasm of bladder neck 185 Malignant neoplasm of prostate 599.72 Microscopic hematuria 599.72 Microscopic hematuria 236.5 Neoplasm of uncertain behavior of prostate 239.5 Neoplasm of unspecified nature, other
genitourinary organs 788.43 Nocturia 788.43 Nocturia 600.11 Nodular prostate with urinary obstruction 600.11 Nodular prostate with urinary obstruction 600.10 Nodular prostate without urinary obstruction 600.10 Nodular prostate without urinary obstruction 793.6 Non-specific (abnormal) findings on radiological and other examination of abdominal area, including retroperitoneum 793.7 Non-specific (abnormal) findings on radiological and other examination of musculoskeletal system 793.6 Non-specific (abnormal) findings on radiological and other examination of abdominal area, including retroperitoneum 793.7 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 788.20 Retention of urine, unspecified 788.20 Retention of urine, unspecified 198.5 Secondary malignant neoplasm, bone and bone marrow 198.82 Secondary malignant neoplasm, genital organs 196.6 Secondary malignant neoplasm, intrapelvic lymph nodes 196.5 Secondary malignant neoplasm, lymph nodes of inguinal region & lower limb 196.8 Secondary malignant neoplasm, lymph nodes of multiple sites 788.62 Slowing of urinary stream 788.62 Slowing of urinary stream 788.65 Straining on urination 788.65 Straining on urination 602.9 Unspecified disorder of prostate 602.9 Unspecified disorder of prostate 601.9 Unspecified prostatitis 601.9 Unspecified prostatitis 788.63 Urgency of urination 788.63 Urgency of urination 788.41 Urinary frequency 788.41 Urinary frequency 788.64 Urinary hesitancy
788.64 Urinary hesitancy 788.30 Urinary incontinence, unspecified 788.30 Urinary incontinence, unspecified 599.60, 599.69 Urinary obstruction