Saturday, March 14, 2009

Billed For Your Free PSA Test? What To Do.

(Updated 06/15/11)

News - - On January 1, 2011, some new improvements to Medicare went into effect. These include a free yearly physical exam for seniors age 65 and older.

The exam needs to be billed as a "Wellness visit". It is coded with CPT codes

"G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit

G0439 – Annual wellness visit; includes a personalized prevention plan of service (PPPS); subsequent visit"

On the first visit, the doctor takes a family history, sets up a screening schedule ("Come back in a year!"), and may possibly be able to charge just a bit more. The second visit is as usual.

So, for a person just coming into Medicare, there is

- at age 65: The "Welcome to Medicare" exam. Google it. It's massive.
- at age 66: The first "Wellness Visit". A history is taken. CPT code G0438.
(The first "Wellness Visit" may get folded into the "Welcome to Medicare" exam.)
- at age 67 and beyond: The annual "Wellness Visit". CPT code G0439.

What has happened to the PSA test?
"Medicare covers 1 PSA test every year AND 1 DRE test every year for Medicare beneficiaries ages 50 and older. There is no coinsurance or Part B deductible for the PSA test, but they both apply to the DRE test."
Here's the whole story.

It looks like the PSA test should henceforth bill naturally within the context of the yearly "Wellness Visit". A full prostate exam includes both a PSA blood test and a digital rectal exam, 0r DRE. You can't bill the blood test to Medicare without billing a DRE as well. So the "Wellness Visit" should include a DRE. And a PSA blood test.

For those who are between 50 and 65 and are on Medicare, other rules may apply.

This year, I had my annual physical - my first "Wellness Visit" - on 2/10. The PSA test was billed correctly and no issues developed.

(- - updated 3/26/2009 - - )

...The collection letter arrived two weeks ago for the bill for my free yearly prostate cancer screening test. Once again, the clinic had screwed up the billing. This time, they used an obesity diagnosis code to justify my PSA screening test billing. "Not medically necessary" was Medicare's conclusion. Perfectly logical, given the diagnosis code.

So I blogged a screaming storm.

The Director for Patient Advocacy of the no-longer-to-be-named diagnostics company that sent the bill to Medicare telephoned today. He explained in better detail than I was given locally how medical billings work. I have updated this posting to reflect his new info, and have generalized the name of the-company-which-is-not-to-be-named to "diagnostic services".

Do you have an inscrutable diagnostic services bill? Let's look at it.

Do the titles of the tests appear in the left-most column? Is there a billing code next to each test in a column labeled "CPT Codes"? This billing code is provided by the diagnostic services.

Below the list of tests may be a line: "ICD-9 Codes:" and a list of codes. These are diagnosis codes provided by the clinic or your doctor. They have to agree with the billing codes, or Medicare rejects the billing.

My clinic's billing clerk selected the obesity diagnosis code - 278.00 - to justify my PSA test. Google the phrase "ICD-9 Codes" and your diagnosis numbers one by one, and you can find the flaws, folks. They can be thrilling.

The correct diagnosis code for PSA (full) screening is the ICD-9 diagnosis code of V76.44. When the diagnostic services sees this code they apply HCPCS billing code G0103 to the bill and send it to CMS (Medicare) for payment. So they tell me.

Here's the memo of August 22, 2003, saying that they should do this. The memo.

If somebody has their doctor put a V76.44 diagnosis code on a test billing and the diagnostics service fails to bill the test G0103, please comment below.

When the clinic sends a bad diagnosis code, that forces Medicare to reject the bill. Medicare's rejection tells Blue Cross not to pay the supplemental insurance. Then the diagnostic service that runs the test wants $97. For my free test. Two years in a row. For me and for many more?

Me and how many more?

Are there perhaps hundreds of other geezers who also get their yearly physical at this clinic (55th and Cottage Grove - you know who you are) who have also had to pay for their free PSA tests? This test has been around for 8 years. Each patient may have had a number of tests and spent many hundreds of dollars that they should not have had to spend.

That's at one clinic. How many clinics miscode these screenings?

How many different kinds of screening tests are forced into miscodings by bad data?

Who is then liable? Blue Cross? The diagnostics service? Medicare?

Tons of clinics miscode. Hundreds of sites advise wrong codes online. They advertise their own liability. At the same time, CMS and the College of Physicians post the correct codes. Is this a class action lawyer's heaven, or what?

Google 84153 PSA screening to discover a list of 500 healthcare sites about 50% of which specify publicly the wrong 84153 billing code for screenings.
Google -> 84153 V76.44 - - to discover sites that recommend using the wrong billing code with the right screening diagnosis.

Google -> screening CPT - - to discover other instances where CPT treatment codes are used to bill screening tests. Where a CPT code is specified as being in use, further research may discover a HCPCS screening code that has replaced it.

Google -> screening ABN - - to discover which uses of the ABN form commit patients to pay the cost when a screening test is rejected by Medicare. The codes recommended for these other tests may similarly have been obsoleted by new HCPCS codes.

May the force be with you.

My clinic's diagnostics service has posted on their web site the CPT billing code 84153 as the only recommended code for the PSA (full) test. Despite their disclaimers of responsibility, it well may be seen and used by many coding clerks. It may be in their coding manual.

Their web site tells coders to use code 84153 for all PSA(total) billings. As of March 15, 2009, that's what's on their site. Print it out yourself. It's evidence that may save your job, coders.

As noted above, this code was retired from screening use on August 22, 2003. The 2005 manual from CMS tells coders on page 90 to use the HCPCS code G0103. It does not give PSA screening as a use for the 84153 CPT code.

We repeat...
The correct billing code for the screening PSA test is G0103, an HCPCS code, and it wants an ICD-9 diagnosis code of V76.44.
The wrong billing code is 84153, a Common Practice Treatment code, or CPT code. Unless there is a cancer-related diagnosis code, it is rejected.
V76.44 is not listed among the diagnosis codes that support 84153, and code 84153 is for use with case management only, so far as I have been able to determine. But 84153 is the only code that the diagnostics service recommends.

This may be to their detriment.

So I'm filing an appeal with CMS. I may also write a note to the legal department of the hospital that sponsors my clinic and another to the clinic director. They may want to assess their potential liabilities. I think they may be at risk.

-- -- --
Update: When I called Medicare about appealing, they told me to call the clinic and ask for a doctor's note to tell Medicare how to change the code. I did this, the clinic jumped into action to cover their tails, and the problem will be solved shortly, they say. We hope so. Details below.

Update: Sent an email to the President using the link at Until Sebelius gets sworn in as HHS Secretery, it may sit in her in-box. Also sent notes to local folk. Told all my friends, including the guy who advises on Medicare issues down at the Senior Center.

Update: The director for billing at the clinic really wants me to wait and see what happens with the latest coding update they sent in. That is the "elevated PSA" diagnosis code. We should know in 20 more days.

In the meantime, if I get another letter from the diagnostic service demanding payment, I will ask for a court date. I want to show a judge their bill. There is no extension of costs to the totals column, no indication that their total on the bill reflects the PSA billing for which I signed the ABN promise-to-pay. The reader must deduce any link. Then I will show judge the prior year's bill, which goes further, omitting any listing for the PSA test entirely, although that's what it was they billed me for. I have already scanned the billing and am waiting and ready for the chance for show-and-tell.

Of course, the pitch is that I should go ahead and pay the bill and then wait for the clinic to correct its errors. Or finally give up. I did that last year. It can't happen twice.

If Medicare rejects the billing once again, will the clinic break down and use G0103?
-- -- --

I may also write the AMA. The diagnostics service says on their bill and on their site that the codes are approved by the American Medical Association. Does the AMA know that their stamp of approval has been put on flawed data? One wonders what the AMA may assess as its own liability for this use of its stamp.

And now I have heard from the diagnostics service...

They place themselves in a hellish position by finally having to collect on all this.

They send clients bills with their company's name at the top, a list of the tests that were done and at the bottom of the bill, the amount finally due. How could they not themselves be the sinners?

The bill they send does not even look right. The column with the total to be paid at the bottom shows nothing above it in the column. The very bill is defective. The billing items are not properly extended over into the columns. To anybody who ever typed an invoice, this looks very strange, right from the start. Uniform Commercial Code and all. Smells like sinners, from the start. You cannot see which tests contributed to the total you are asked to pay. Smoke and mirrors. Smells like sinners.

Their local people say that they do not recommend billing codes to the clinics, and I believe them. But their corporate web site shows bad data. Note at the top of the page that it suggests using this test for BPH. Medicare has said that if you are going to use this test to check for BPH, you need to fold it into the yearly G0103 PSA screening. They won't pay otherwise. The service's web site does not show the G0103 screening billing code.

The service's site uses computer generated screens which rather obviously present data that comes from a database.

Link to the above, do a "View Source" in your browser and you will see none of the usual programmer acknowledgements, no larger references. This is computer generated - ColdFusion is running as a front end on Eclipsys, perhaps. So - Who - manages this database, and how else is it used? What other appearances does this bad data make? Their coding manual?

Could the database accept some updates? It might help the rest of their effort go more smoothly. In its present very visible form, this page really makes one wonder about the worth of a very good company. It frankly justifies bad billings. A mis-billed person would look at that page and give up. Some clients may have done so.

So the diagnostics service's billing department has to patiently explain over and over to the unbelieving patient that these bad codes came from the clinic, not from the service. The patient - whose eyes tell him otherwise - screams and moans.

If the design of their bill were to include descriptions for the codes used, errors would self-correct. If the bill explained that these codes were basically chosen by the clinic coder - and here's his phone number - this could greatly reduce their corporate emotional burden. It might also get their bills paid a lot more quickly.

Give patients what they need to correct the coders.

Miscoding the screenings - and charging the client - is so common on these PSA tests that the clinics require older male patients who are in for their annual physical exam to sign an "ABN form" promising to pay if Medicare rejects the clinic's choice of PSA billing codes.

So - here's how to keep it from happening to you. I checked this with my coder, and he's totally cool with the idea.

At your next physical, when the clinic asks you to sign the ABN for the free PSA screening test, just attach a note:

"Please use ICD-9 diagnosis code V76.44 to bill this PSA screening test. This is the code that Medicare requests."

... and it should be billed correctly. If you've not had eleven months or more between tests, it could be rejected. But not for a bad diagnosis code. Mention it to your doctor.

If you do ever get a miscoded billing, just call the clinic and tell the desk clerk that you are appealing a miscoded billing to Medicare. Medicare needs you to get a doctor's note asking them to change the billing to the correct code. The clinic will very much want to fix it themselves.

"Getting a note from doctor" sets fires.

A very complex system has been created by very intelligent people. They then left it to be run by the average Joes and Noras of the world, good souls who must struggle daily with its endless complexity. I have seen two men die young from trying to manage the programming of such systems. Programs are poorly documented, the updates and patches less so if at all, and systems departments run black box dinosaurs that produce dino dung.

Good people can make it all well again. Just get a note from doctor.

On the posting below, I list some healthcare sites that tell the world they use the correct coding.


Anonymous said...

Exactly what happened to me. $115 for my "free" screening PSA test. Thanks for the info in your blog. The codes you recommend match what I was able to discover from various on-line sources. Now to get them corrected and then reimbursement.

It seems my doctor's office has to take half the blame for the missing (V76.44) diagnosis code and the nameless lab for the wrong CPT code. Good luck.

Anonymous said...

Bless you!

I've started to help my dad with bills lately, and we received a statement for his PSA screen that said Medicare disallowed the claim.

I work in a pharmacy, so I don't know much about the medical side of coding things, but suspected this was the problem.

After looking on many "official" websites, I was confused and unable to get a clear answer on which codes should have been used.

So I did a general web search, and your blog popped up somewhere on there. You have given me the simplest most logical explanation of how to get this fixed.

Thank you!

Anonymous said...

Thank You sooooooooo very much. I work for a Health care company and we are not allowed to tell the provdier what to list, only that it is wrong.
The provdiers can go to the web sites as easily as you and I can but, they don't. The information is out there.
I hate to see member's getting billed for a coding mistake and I am unable to tell them why. I will refer them to this blog instead, that way I can tell them what is wrong without saying it over the phone (which is recorded).
Thank you again,
Customer Service