National Coverage Determination: Prostate Specific Antigen
National Coverage Determination
CPT Code: 84153
Prostate Specific Antigen
CMS Policy Number: 190.31
Description: Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer. Three to 6 months after radical prostatectomy, PSA is reported to provide a sensitive indicator of persistent disease. Six months following introduction of antiandrogen therapy, PSA is reported of distinguishing patients with favorable response from those in whom limited response is anticipated.
PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer. PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment.
Indications:
PSA is of proven value in differentiating benign from malignant disease in men with lower urinary tract signs & symptoms (e.g., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia & incontinence) as well as with patients with palpably abnormal prostate glands on physician exam, and in patients with other laboratory or imaging studies that suggest the possibility of a malignant prostate disorder. PSA is also a marker used to follow the progress of prostate cancer once a diagnosis has been established, such as detecting metastatic or persistent disease in patients who may require additional treatment. PSA testing may also be useful in the differential diagnosis of men presenting with as yet undiagnosed disseminated metastatic disease.
Limitations:
Generally, for patients with lower urinary tract signs or symptoms, the test is performed only once per year unless there is a change in the patient’s medical condition.
Testing with a diagnosis of in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.
ICD-10 | Descriptor |
C61 |
Malignant neoplasm of prostate |
C67.5 |
Malignant neoplasm of bladder neck |
C77.4 |
Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes |
C77.5 |
Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes |
C77.8 |
Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions |
C79.51 |
Secondary malignant neoplasm of bone |
C79.52 |
Secondary malignant neoplasm of bone marrow |
C79.82 |
Secondary malignant neoplasm of genital organs |
D07.5 |
Carcinoma in situ of prostate |
D40.0 |
Neoplasm of uncertain behavior of prostate |
D49.511 |
Neoplasm of unspecified behavior of right kidney |
D49.512 |
Neoplasm of unspecified behavior of left kidney |
D49.519 |
Neoplasm of unspecified behavior of unspecified kidney |
D49.59 |
Neoplasm of unspecified behavior of other genitourinary organ |
M33.03 |
Juvenile dermatomyositis without myopathy |
M33.13 |
Other dermatomyositis without myopathy |
M33.93 |
Dermatopolymyositis, unspecified without myopathy |
N13.9 |
Obstructive and reflux uropathy, unspecified |
N32.0 |
Bladder-neck obstruction |
N40.0 |
Benign prostatic hyperplasia without lower urinary tract symptoms |
N40.1 |
Benign prostatic hyperplasia with lower urinary tract symptoms |
N40.2 |
Nodular prostate without lower urinary tract symptoms |
N40.3 |
Nodular prostate with lower urinary tract symptoms |
N41.9 |
Inflammatory disease of prostate, unspecified |
N42.9 |
Disorder of prostate, unspecified |
R31.0 |
Gross hematuria |
R31.1 |
Benign essential microscopic hematuria |
R31.21 |
Asymptomatic microscopic hematuria |
R31.29 |
Other microscopic hematuria |
R31.9 |
Hematuria, unspecified |
R32 |
Unspecified urinary incontinence |
R33.9 |
Retention of urine, unspecified |
R35.0 |
Frequency of micturition |
R35.1 |
Nocturia |
R39.11 |
Hesitancy of micturition |
R39.12 |
Poor urinary stream |
R39.14 |
Feeling of incomplete bladder emptying |
R39.15 |
Urgency of urination |
R39.16 |
Straining to void |
R93.5 |
Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum |
R93.6 |
Abnormal findings on diagnostic imaging of limbs |
R93.7 |
Abnormal findings on diagnostic imaging of other parts of musculoskeletal system |
R94.8 |
Abnormal results of function studies of other organs and systems |
R97.20 |
Elevated prostate specific antigen [PSA] |
R97.21 |
Rising PSA following treatment for malignant neoplasm of prostate |
Z79.810 |
Long term (current) use of selective estrogen receptor modulators (SERMs) |
Z79.811 |
Long term (current) use of aromatase inhibitors |
Z79.818 |
Long term (current) use of other agents affecting estrogen receptors and estrogen levels |
Z79.890 |
Hormone replacement therapy |
Z79.899 |
Other long term (current) drug therapy |
Z85.46 |
Personal history of malignant neoplasm of prostate |