HCPCS code G0103: Prostate Cancer Screening; Prostate Specific Antigen Test (PSA)

## **Documentation requirements** For a G0103 claim to be considered for payment, the medical record must support medical necessity and to prove that the test was performed for screening purposes. Key documentation requirements include: - **Patient eligibility**: The patient must be a male older or equal to 50 years old and preferably a Medicare beneficiary. - **Screening intent**: The documentation must clearly state that the purpose of the test was for screening for malignant neoplasm of the prostate. To add, one must add the date of the prior PSA screening to prove the 12-month interval compliance. - **Absence of symptoms**: The patient must be asymptomatic. If the patient has any signs or symptoms related to a prostate issue (e.g., frequent urination, pain, blood in urine), the test is considered diagnostic, and a different code should be used. - **Diagnosis code**: The appropriate diagnosis code for screening is Z12.5 (Encounter for screening for malignant neoplasm of prostate). This is a crucial detail for distinguishing the claim from a diagnostic test.

## **Billing requirements** To avoid denial of claims, the following billing requirements must be kept in mind when billing for HCPCS code G0103: - **Frequency**: G0103 is typically covered once every 12 months. Medicare's frequency calculation begins the month after the previous test was performed, so a patient is eligible for a new screening test 11 months after the month of their last one. - **Patient demographics**: For Medicare, the patient must be a male beneficiary who has attained age 50. - **Payment**: For Medicare, the deductible and coinsurance are often waived for this preventive service, a key difference from many diagnostic tests. - **Ordering provider**: The screening must be ordered by the patient's physician or by a qualified non-physician practitioner (e.g., physician assistant, nurse practitioner) who is authorized by state law to perform the service. - **Billing for diagnostic vs. screening**: It is essential to use G0103 for screening only. If a patient presents with symptoms that warrant a PSA test, the claim should be billed with a CPT code like 84153 (Prostate specific antigen (PSA); total) and a diagnosis code that reflects the patient's symptoms or condition (e.g., R97.21 for elevated PSA, or a specific diagnosis code for prostatic hyperplasia). Mixing screening codes with diagnostic codes can lead to denials. Do note that no coinsurance, copayment, or deductible applies under Medicare preventive services.

## **Other relevant codes** - **G0102**: This HCPCS code is for the screening digital rectal examination (DRE). It is often performed in conjunction with the PSA test, but is billed separately. Unlike G0103, Medicare may apply coinsurance and a deductible to G0102. - **84152, 84153, 84154**: These are CPT codes for diagnostic PSA tests. - **Z12.5**: As mentioned above, this is the primary ICD-10 diagnosis code for screening for malignant neoplasm of the prostate. - **Z85.46**: Personal history of malignant neoplasm of prostate. This code is for patients who have a history of prostate cancer and are being monitored after treatment.