PSA not covered by Medicare

[Muggs1]

Is it true Medicare only pays for one PSA per year? This is my first year, getting PSA every 3 months after radiation, kinda surprised to see they didn’t pay

[maley2711]

From what I understand, quarterly PSA checks after radiation are standard......but Medicare declined to pay for your tests? Doesn't seem right, but......??? The lab must know if this is correct.....assuming they help many men with PSA tests.

[Vynbal]

I have had multiple PSA tests per year w/ no Medicare problem. I imagine that for pre-cancer screening that medicare may only pay for one per year. Perhaps it is a coding error.

[Concerned-wife]

many men with prostate cancer have PSA covered by Medicare every 3 months.

[Murk]

Never ever had push back from Medicare on any of my every 3 month interval Ultrasensitive PSA Tests.

[Ron53]

As my PSA has been rising of late, Oncologist has wanted PSA checked monthly .... and Medicare is paying. I do see on my Medicare statement, that it is not Part B, but "Hospital Outpatient" with I believe is Part A.

[Muggs1]

thank you all

[dhccpa]

No, not true, although it may depend on your diagnosis (and if you have even been diagnosed). I've had at least seven this calendar year.

[Muggs1]

Upon further review, Quest billed my AARP supplement

[Don_1213]

Thought I mentioned this last week...

It's a problem with the organization ordering the PSA test's coding for the test. Case in point, I've received multiple PSA tests through the past 6 years, some of them monthly (differernt MD's wanting their own test...) and once two in the same blood-draw session.

Then I noticed that Medicare denied Quest payment for 1 in a recent blood workup for my quarterly exam with my primary care doc. Why? It was written up as:

Prostate Cancer Screening: prostate specific antigen test (psa) (G0103) - and it was denied because it "has not been 12 months since your last test/procedure of this kind"

That code is for someone who does not have PCa - for their annual checkup. Since I'd had PSA done about 3 months ago - that test was rejected.

"G0103 is the HCPCS code for a prostate-specific antigen (PSA) blood test. This test is used to screen for prostate cancer and is covered by Medicare once every 12 months for men who are 50 or older."

Ones that got paid were coded: "84153 - Psa (Prostate Specific Antigen) Measurement, Total" - same test, different code.

That code - looked up by the number is: "Medical code 84153 is the Current Procedural Terminology (CPT) code for a blood test that measures the level of prostate specific antigen (PSA) in the blood. PSA is a protein produced by the prostate gland, and the test is used to screen for prostate cancer and monitor the progression of the disease. "

I did the bolds.

Here is an explaination of the differences - since this seems to be a common mistake:

aapc.com/codes/coding-newsl...

It's all in the coding. When hiring MD's now in general practices (and probably specialty practice) skill in coding is a big factor in being hired. An MD with proof of being a productive coder ($$$$) - perhaps with lesser medical skills - will probably be hired (this was according to my GP who I've been going to for 30 years.. and we're friends.)

I have to talk to my GP's coding person - they joined a group practice kind of thing who provides them with coding people. What seems to have happened is whoever coded in the prescription for my blood test didn't know it should have been 84153. I would think Quest would have an automatic appeal process in place for this sort of error, but guess not..

Ain't it all fun..

[gbloomqu]

You can purchase a PSA test from Lab Corp for around $30.

[Muggs1 in reply to gbloomqu]

Thanks, it’s $75 at Quest when I order it, but when my doc ordered it, they’re charging me $200

[Muggs1]

thanks for all the helpful advice, Quest said they didn’t have my Medicare number so that was the reason 🤪

[Spinel_Cutter]

Appeal it. Have your doc write a letter of medical necessity, I'll bet the appeal will be granted and you'll not have to pay. I suspect the 1x/year relate to those w/out prostate cancer treatment.