Preventive Services

Preventive Services Guide


Prostate Cancer Screening

Prostate cancer is the second most common cancer in men in the United States, after skin cancer. Older men, African-American men and men who have a family history of prostate cancer have a greater risk of developing prostate cancer.

Coverage Criteria

  • Annually for all male Medicare beneficiaries aged 50 and older (at least 11 months have passed following the month in which the last Medicare-covered screening DRE was performed (for digital rectal exams) or PSA test was performed (for PSA tests)
    • Coverage begins day after 50th birthday
  • Screening PSA blood test must be ordered by beneficiary’s physician or PA, NP, CNS or CNM
    • Coinsurance and deductible waived
    • Fully knowledgeable about beneficiary’s medical condition
    • Responsible for explaining the results of the test
  • Screening DRE must be performed by doctor of medicine or osteopathy, PA, NP, CNS or CNM authorized under state law to perform examination
    • Coinsurance and deductible apply
    • Fully knowledgeable about beneficiary’s medical condition
    • Responsible for explaining results of examination

HCPCS/CPT Coding

  • G0102: Prostate cancer screening; DRE
  • G0103: Prostate cancer screening; PSA test

Diagnosis Coding

  • ICD-10 Codes
    • Z12.5

Additional ICD-10 codes may apply. See the CMS ICD-10 webpage for individual CRs and the specific ICD-10-CM codes Medicare covers for this service, and contact your Medicare Administrative Contractor (MAC) for guidance.

Reimbursement

Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

Billing Tips – Correct Coding Requirements

  • Billing and payment for a DRE (G0102) is bundled into the payment for a covered E/M service (CPT codes 99202–99456 and 99499) when the two services are furnished to a patient on the same day. If the DRE is the only service or is provided as part of an otherwise noncovered service, HCPCS code G0102 would be payable separately if all other coverage requirements are met.

Common Claim Denials

  • This service is not covered for patients under 50 years of age
  • This service is not covered until after the patient’s 50th birthday
  • Service is being denied because it has not been 12 months since your last test/procedure of this kind

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Reviewed 9/27/2024