Prostatic Acid Phosphatase(PAP)-HTML

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Contractor's Policy Number

97-10-R3

Contractor's Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LMRP Title

Prostatic Acid Phosphatase (PAP)

AMA CPT Copyright Statement

CMS National Coverage Policy

Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

CMS Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

04/28/1997

Original Policy Ending Date

Revision Effective Date

10/01/2003

Revision Ending Date

09/30/2003

LMRP Description

Prostatic acid phosphatase is a laboratory test performed to evaluate the effectiveness of treatment for prostatic cancer.

Indications and Limitations of Coverage and/or Medical Necessity

Prostatic acid phosphatase testing may be used as an aid in staging and following cancer of the prostate to evaluate the effectiveness of treatment for prostatic cancer. Many physicians are now using the newer and more specific Prostate Specific Antigen (PSA) test for their prostate cancer patients.

CPT/HCPCS Section & Benefit Category

Pathology and Laboratory/Chemistry

Type of Bill Code

13X, 14X, 83X

Revenue Codes

30X

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

84066

Assay prostate phosphatase

Not Otherwise Classified (NOC)

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Covered for:

170.2		Malignant neoplasm of vertebral column, excluding sacrum and coccyx
185		Malignant neoplasm of prostate
188.5		Malignant neoplasm of bladder neck
188.8		Malignant neoplasm of bladder, other specified sites of bladder
196.5		Secondary malignant neoplasm, lymph nodes in inguinal region and lower limb
196.6		Secondary malignant neoplasm, intrapelvic lymph nodes
196.8		Secondary malignant neoplasm, lymph nodes of multiple sites
198.5		Secondary malignant neoplasm, bone and bone marrow
198.82		Secondary malignant neoplasm, genital organs
233.4		Carcinoma in situ, prostate
236.5		Neoplasm of uncertain behavior, prostate
239.5		Neoplasm of unspecified nature, other genitourinary organs
596.0		Bladder neck obstruction
599.7		Hematuria
600.00		Hypertrophy (benign) of prostate without urinary obstruction
600.01		Hypertrophy (benign) of prostate with urinary obstruction
600.10		Nodular prostate without urinary obstruction
600.11		Nodular prostate with urinary obstruction
600.20		Benign localized hyperplasia of prostate without urinary obstruction
600.21		Benign localized hyperplasia of prostate with urinary obstruction
600.3		Cyst of prostate
600.90		Hyperplasia of prostate, unspecified, without urinary obstruction
600.91		Hyperplasia of prostate, unspecified, with urinary obstruction
601.0-601.1		Acute or chronic prostatitis
601.4		Prostatitis in diseases classified elsewhere
601.8		Other specified inflammatory diseases of prostate
601.9		Prostatitis, NOS
602.1		Congestion or hemorrhage of prostate
602.3		Dysplasia of prostate
602.8-602.9		Disorder of prostate
790.93		Elevated prostate specific antigen (PSA)
V10.46		Personal history of malignant neoplasm of the prostate
V71.1		Observation for suspected malignant neoplasm

Diagnoses that Support Medical Necessity

As listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Reasons for Denial

All other indications not listed in the "Indications and Limitations of Coverage" section of this policy,
The service is for screening purposes,
The service is not medically necessary,
The medical record does not verify that the service described by the HCPCS code was provided, and;
The service does not follow the guidelines of this policy.

Non-covered ICD-9 Codes

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Non-covered Diagnoses

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Coding Guidelines

To report this service, use the appropriate HCPCS code,
All of the coverage criteria must be met before this service can be reimbursed by Medicare,
Medicare would not expect to see the PSA billed on the same day as the prostatic acid phosphatase (PAP),
Diagnosis (es) must be present on any claim submitted, and be coded to the highest level of specificity, and;
The diagnosis codes(s) must be representative of the patient's condition.

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.

Utilization Guidelines

Medicare will monitor the utilization of this laboratory test through the Focused Medical Review (FMR) process.

Other Comments

Financial Responsibility:

Provider Liable

The provider of the service or the ordering physician must have notified the patient in writing, prior to the service, and obtained a signature verifying Advance Beneficiary Notice. Without prior notice, services denied as not medically necessary cannot be billed to the beneficiary. The provider is liable.

Beneficiary Liable

If there is clear evidence that the beneficiary was issued and signed an Advanced Beneficiary Notice (ABN) prior to the service, the liability rests with the beneficiary. Claims for dates of service prior to January 1, 2003 should contain the condition code 20 and occurrence code 32, with date to signify that an ABN was issued to the beneficiary. Absence of these codes will result in a provider liable determination

Claims for dates of service beginning January 1, 2003 should contain the occurrence code 32 with date to signify that an ABN was issued to the beneficiary. Absence of this code will result in a provider liable determination.

Reference: PM AB-02-168, CR 2415

Sources of Information and Basis for Decision

· TrailBlazer Health Enterprises, Inc., Provider Bulletin No. 013, September 27, 1996.

· Annual ICD-9-CM Code update, FY 2004, PM AB 03-091, CR 2763.

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Advisory Committee Meeting Date:

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

09/12/2001

Revision History

Number	Date	Change
97-10-R3	10/01/2003	Annual ICD-9 update with deletion of codes 600.0, 600.1, 600.2, 600.9 and addition of codes
		600.00, 600.01, 600.10, 600.11, 600.20, 600.21,
		600.90, 600.91. (PM AB 03-091, CR 2763). HCPCS descriptor shortened.
97-10-R2	09/12/2001	Expansion of ICD-9 codes due to addition of new codes for 2002. (Provider
		Bulletin 09/12/2001)
97-10-R1	11/17/2000	Addition of ICD-9 codes 600.0-600.9 due to expansion and clarification of codes.
		ICD-9 code 600 deleted due to changes. (Provider Bulletin 11/17/2000)

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT http://www.marylandmedicare.com/.

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.