In Memoriam: Gregory B. Root
National Coverage Determination
Back to NCD List
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.
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.
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.
Frequency Limitations: For patients with lower urinary tract signs or symptoms, total PSA is performed only once per year unless there is a change in the patient's medical condition. Medicare covers a screening total PSA test one each year for men over 50 years of age.
To review all requirements of this policy, please see:
CMS NCD listing by Chapter
Covered ICD-10 Codes.
.... and many more.
|C61||Malignant neoplasm of prostate|
|C67.5||Malignant neoplasm of bladder neck|
|C77.4||Sec and unsp malig neoplasm of inguinal and lower limb nodes|
|C77.5||Secondary and unsp malignant neoplasm of intrapelv nodes|
|C77.8||Sec and unsp malig neoplasm of 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|
Sorry, you need to login or register to view additional sections of this Medicare policy.
Click here for publications catalog.
The content and format of the following files and/or webpages are
copywritten and the property of Wheaton Partners, LLC - dba CodeMap®. All
recipients of these files agree not to distribute, reproduce and/or use the
information contained within, in any manner not expressly agreed upon by the
user and Wheaton Partners, LLC - dba CodeMap®.
All code-pairs and Medicare coverage information are compiled directly from Center for Medicare and
Medicaid Services (CMS) and Medicare Contractor coverage policies. CodeMap®
has made every reasonable effort to ensure the accuracy of the information
contained. However, the ultimate responsibility for correct
coding and claims submission lies with the provider of services. Both CMS and
Medicare contractor coverage policy information may change at any time.
CodeMap® makes no representation, warranty, or guarantee that this compilation
of coverage policy information is error-free or that the use of this information
will result in Medicare coverage and subsequent payment of claims. Final
coverage and payment of claims are subject to many factors exclusively
controlled by CMS and its contractors.