G0103 — Prostate cancer screening; prostate specific antigen test (psa)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Document member age and risk status (e.g., average-risk versus high-risk; high-risk examples cited: African-American race and family history of prostate cancer) to support preventive PSA screening eligibility (policy states preventive screening ages: 45+ average-risk; 40+ high-risk).
- Document signs or symptoms of prostate cancer when performing PSA testing for diagnostic purposes (policy: "PSA testing for men of all ages with signs or symptoms of prostate cancer").
- Document prior elevated PSA results when performing annual PSA screening for routine follow-up (policy: "Annual PSA screening when used for routine screening in men with previously elevated PSAs or signs or symptoms of disease.")
- Document follow-up intent when PSA testing is performed for monitoring men with known prostate cancer (policy: "for follow-up of men with prostate cancer").
Key Coverage Criteria
- ICD-10 codes listed as covered if selection criteria are met: C61; D07.5; D29.1; D40.0; N40.0 - N40.3; N42.30 - N42.39; R97.20 - R97.21; Z12.5; Z15.03; Z80.42; Z85.46.
- PSA testing for men of all ages with signs or symptoms of prostate cancer.
- Annual PSA screening when used for routine screening in men with previously elevated PSAs or signs or symptoms of disease.
- Prostate-specific antigen (PSA) screening as a preventive service for men 45 years of age and older who are considered average-risk for prostate cancer.
- Prostate-specific antigen (PSA) screening as a preventive service for men 40 years of age and older who are considered at high-risk for prostate cancer. Risk groups include African-American men and men with a family history of prostate cancer.
- PSA testing for follow-up of men with prostate cancer.
4 Active Policies
CIGNA-A004 — Preventive Care Services - (A004)
HUMANA-EARLY-PROSTATE-CANCER-DETECTION-MA — Early Prostate Cancer Detection - Medicare Advantage
AETNA-CPB-0521 — Prostate Cancer Screening
ANTHEM-CG-LAB-28 — CG-LAB-28 Prostate Specific Antigen Testing
Related Codes
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