Date Posted: Tuesday,
May 02, 2023
Summary: Men's Health Awareness Month is the ideal time to spread information about preventable health problems and encourage early detection and treatment of diseases such as prostate cancer.
Men can suffer from various medical conditions at any age. Being proactive and getting regular screening and checkups can decrease the risk of many issues. Men's Health Awareness Month is observed in June every year to honor the importance of the health and wellness of boys and men.
While heart disease, stroke, diabetes, cancer, and depression affect both men and women, men experience unique issues such as prostate problems. Studies suggest that the average man is less likely to pay attention to health than an average woman. The goal of Men's Health Awareness Month is to spread information about preventable health problems and encourage early detection and treatment of disease among men and boys.
This article focuses on prostate cancer, the most frequently diagnosed cancer in 112 countries and the leading cause of cancer death in 48 countries (U.S. Preventive Services Task Force - USPSTF). Prostate cancer is the second most common cancer found in American men and the second most common cause of cancer death for men in the U.S. About one in seven men receives a diagnosis of prostate cancer at some point in his lifetime. The American Cancer Society (ACS) estimates that, in 2023, there will be about 288,300 new cases of prostate cancer in the U.S. and about 34,700 deaths from prostate cancer.
The prostate gland lies below the bladder. The prostate and seminal vesicles are part of the male reproductive system. Prostate cancer occurs when abnormal cells form and grow in the prostate gland. Cancerous tumors can spread to the nearby organs and tissues. Catching cancer at an early stage can make it easier to treat. Since early-stage prostate cancer often has no symptoms, screening is crucial for early detection, when the chances of treatment success and favorable outcomes are high.
Main Risk Factors for Prostate Cancer
Similar to other chronic health diseases, cancer comes with certain risk factors that increase the chance of developing it. All men are at risk for prostate cancer, though some men face higher risks of getting it.
The risk factors for prostate cancer are:
- Age: The older a man is, the greater the chance of getting prostate cancer. Risks increase after age 50 and about 60% of prostate cancers are diagnosed in men who are 65 or older.
- Family history: Familial or hereditary prostate cancer is the result of a combination of shared genes and environmental or lifestyle factors.
- Race: African American males are at higher risk of being diagnosed with prostate cancer.
It is important for men to know about their risk factors and discuss how to manage them with their doctor.
Prostate cancer grows slowly over time. There may not be any symptoms in the early stage. Symptoms appear when cancer becomes large enough to put pressure on the urethra.
Advanced prostate cancer can cause many symptoms:
- Difficulty urinating
- Weak or interrupted flow of urine
- Frequent urination, especially at night
- Pain or burning when urinating
- Urinary retention
- Blood in the urine or semen
- Chronic pain in the back, hips, or pelvis
- Painful ejaculation
Symptoms of prostate cancer vary among individuals, and some will not have symptoms at all. Also, these changes are similar to those of other genitourinary conditions. Discussing recurring symptoms with the doctor and getting evaluated can help rule out conditions and lead them to find the true cause of your symptoms. Prostate cancer can spread to the lymph nodes of the pelvis, throughout the body, or to the bones.
Screening for prostate cancer is done to find evidence of the disease before symptoms appear. Detecting cancer at an early stage when it is less likely to have spread will improve chances of treatment success. The prostate-specific antigen test is used in conjunction with a digital rectal exam to screen for prostate cancer.
- Prostate Specific Antigen (PSA) Test: The PSA test is the standard test used to screen for prostate cancer. Prostate specific antigen (PSA) is a protein produced by both malignant and normal tissue in the prostate. The PSA test measures the amount of PSA in the blood. High levels of PSA may indicate the presence of prostate cancer.
- Digital rectal examination (DRE): A DRE checks the consistency, size, and texture of the prostate gland. The test can reveal abnormalities such as nodularity, induration, tissue inconsistency, or asymmetry of the prostate.
If these tests yield abnormal results, further testing (such as a prostate biopsy) is usually done to see if the individual has cancer.
Benefits of PSA Screening
A StatPearls publication (2022) on prostate cancer screening notes that PSA has many significant advantages:
- Though it is nonspecific, PSA is a sensitive and economical test for prostate cancer.
- PSA screening detects prostate cancer before it results in untreatable complications.
- PSA screening has reduced prostate cancer mortality or morbidity. The National Institutes of Health (NIH) reported that prostate cancer-specific mortality decreased by over 44% when PSA testing became widely available in the U.S. (1992).
- Active monitoring, MRI testing, software-assisted fusion registration (MRI-TRUS fusion biopsies), and genomic testing have significantly reduced overtreatment of prostate cancer.
- If all PSA screenings were stopped, the NIH estimates that after ten years, an additional 25,000 to 30,000 men would die annually in the U.S. from prostate cancer that could otherwise have been cured.
"Men should have a PSA, or prostate-specific antigen, check if not every year, every two to three years, to establish a baseline for evaluation of possibly clinically significant prostate cancer in the future," recommends Dr. David Thiel, a Mayo Clinic urologist (https://newsnetwork.mayoclinic.org/).
Concerns About PSA Screening
The U.S. Food and Drug Administration approved PSA for screening in 1994. The PSA test can detect early-stage prostate cancer, making it useful for people with many risk factors and allows some to get the treatment they need before the cancer grows and spreads.
However, there are concerns about PSA:
- Many factors can increase PSA levels in people without cancer and certain factors can lower PSA levels even if a person has prostate cancer.
- Overuse of PSA screening can lead to painful and unnecessary biopsies, as well as over-diagnosis and over-treatment. Aggressive treatment for a disease that is not aggressive can have severe side effects.
However, despite its significant lack of specificity, PSA continues to be the single most widely utilized screening test for detecting prostate cancer at the early stage.
The recommended best practice for physicians is to have a meaningful discussion about pros and cons of the PSA test with every male patient in the age group of 45 to 75 years, including their personal risk of prostate cancer. They should weigh personal history and preferences and help them make an informed decision.
When Should Screening for Prostate Cancer Begin?
Multiple factors, including the individual's age and family history, determine at what age screening for prostate cancer should begin. The ACS recommends the ages at which men should have a discussion about screening with their doctor:
- Age 50 - for men who are at average risk of prostate cancer and have a life expectation of at least 10 more years.
- Age 45 - for men at high risk of developing prostate cancer, including African Americans and men who have a first-degree relative (father or brother) diagnosed with prostate cancer at an age below 65.
- Age 40 - for men at even higher risk-those with more than one first-degree relative who had prostate cancer at an early age.
PSA screening is not recommended for men over 70 years as the USPTF maintains that the risks of false positives outweigh the benefits for them. Guidelines also do not recommend screening for men with a life expectancy of less than 10 to 15 years.
Diagnosis and Staging
Doctors combine the T (tumor), N (node), and M (metastasis) information, PSA level, scan results, and Gleason score to determine the stage of the cancer. The Gleason scoring system is the most common option used for prostate cancer. The lowest Gleason score of 6 is a low-grade cancer, a score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer.
Treatment for prostate cancer depends on the stage and severity of the cancer. Surgery, radiation therapy, and chemotherapy are conventional treatments for cancer that have advanced significantly and are for younger patients who are otherwise in good health. Treatment options are:
- Hormonal therapy to treat early-stage tumors
- Immunotherapy treatment - using a person's own immune system to kill cancer cells
- Chemotherapy for metastatic prostate cancer
- Radiation treatments to treat localized prostate cancer
- Surgery - known as a radical prostatectomy, this operation removes the entire prostate gland and seminal vesicles
Patients who are older or face a higher risk for other diseases can benefit from improvements in diet and lifestyle. These strategies can help subdue the cancer and also boost wellbeing and quality of life. After diagnosis, making healthy choices such as quitting smoking and increasing physical activity can reduce the risk of developing aggressive prostate cancer.
Codes for Prostate Cancer Screening
As prostate screening is one of the most common procedures performed in urology practices, correct coding of the procedure and diagnosis is crucial for accurate claim submission and reimbursement.
There are two types of PSA tests: screening and diagnostic. Screening PSA tests are performed in the absence of signs or symptoms of prostate cancer. Diagnostic PSA tests are performed when the patient has signs or symptoms. Coding for screening and diagnostic PSA tests can be challenging as the requirements differ among payers, including Medicare.
Codes for Prostate Specific Antigen Test and Digital Rectal Exam
Most commercial payers and Medicare cover the cost of annual screening for prostate cancer in beneficiaries over the age of 50.
HCPCS and ICD-10 Codes for Prostate Cancer Screening
The HCPCS codes to bill Medicare for the screening PSA test and DRE are:
- G0103 - Prostate cancer screening; prostate specific antigen test (PSA)
- G0102 - Prostate cancer screening; digital rectal examination
For a Medicare patient, a screening PSA should be reported with G0103, and a diagnostic PSA should be reported using one of the following CPT codes to indicate the type of test:
- 84152 - Prostate specific antigen (PSA); complexed (direct measurement)
- 84153 - Prostate specific antigen (PSA); total
- 84154 - Prostate specific antigen (PSA); free (use only if there is a known PSA elevation)
The ICD-10 diagnosis code for a screening test for a patient with no signs or symptoms of disease is:
- Z12.5 - Encounter for screening for malignant neoplasm of prostate
- Z80.42 - Additional code that should be reported if there is a family history of malignant neoplasm of prostate
The documentation of History of Present Illness should include the factors that may raise PSA levels, which includes an enlarged prostate, urinary-tract infection, prostatitis, prostate biopsy or cystoscopy, certain medications, or older age.
ICD-10 Codes for Diagnostic PSA
If a diagnostic PSA test is performed, report the following ICD-10 codes based on the results:
- R97.20 - Elevated prostate specific antigen (PSA)
- N40.0 - Benign prostatic hyperplasia without lower urinary tract symptoms
- N40.1 - Benign prostatic hyperplasia with lower urinary tract symptoms
For PSA determinations, Medicare may also consider payment for urological signs or symptoms, such as:
- R31.0 - Gross hematuria
- R31.1 - Benign essential microscopic hematuria
- R35.0 - Frequency of micturition
- R35.1 - Nocturia
Codes for a Diagnosis of Prostate Cancer
For a specific diagnosis such as prostate cancer, use the following codes:
- C61 - Malignant neoplasm of prostate
- Use additional code to identify:
-- Hormone sensitivity status (Z19.1-Z19.2)
-- Rising PSA following treatment for malignant neoplasm of prostate (R97.21)
- C79.82 - Secondary malignant neoplasm, genital organs
- C79.9 - Secondary malignant neoplasm of unspecified site
- D07.5 - Carcinoma in situ of prostate
Hormone sensitivity status codes:
- Z19.1 - Hormone sensitive malignancy status
- Z19.2 - Hormone resistant malignancy status (castrate resistant)
Following payer guidelines and knowing local coverage determinations (LCDs) for screening frequency limits and diagnostic codes is crucial for accurate screening and diagnostic PSA testing. Providers should ensure proper documentation in the patient's record to support the coding.
Need to Focus on Prevention and Early Detection
The overall goal of cancer screening is to reduce the number of people who die from the disease, lower the number of people who develop the disease, and eliminate deaths from cancer altogether.
But what if people miss screenings? This happened during the COVID-19 pandemic.
A new, nationwide study led by researchers at the American Cancer Society found that millions of people in the U.S. continued to miss critical screening tests for breast, cervical, colorectal, and prostate cancer during the second year of the pandemic. The study showed that close to 700,000 fewer men reported having a prostate cancer screening test. The authors stress the importance of getting people back to scheduling regular cancer screening tests to prevent and catch cancer at its earliest stages when it might be easiest to treat.
For most patients who are eligible for PSA testing, a yearly screening test is recommended. There are two new tests that better evaluate prostate cancer risk than PSA, according to John Hopkins Medicine: the FDA-approved prostate health index (PHI) and the Prostate Cancer Urine Test. Both of these new tests are more accurate than the PSA test. John Hopkins Medicine says that as it is better at detecting aggressive cancer, PHI reduces the need for an invasive biopsy and helps the physician develop a more targeted treatment plan.
Men's Health Awareness Month is about educating people about preventive steps to keep disease at bay. When it comes to prostate health, while there's no proven prevention strategy, making healthy choices such as exercising regularly and following a healthy diet could contribute to a lower risk of prostate cancer.
Meghann Drella, CPC, is a Senior Solutions Manager at Managed Outsource Solutions (MOS), and is responsible for practice and revenue cycle management in the Healthcare Division. She has a formal education in Medical Coding and Billing and over 12 years of hands on experience in the field. She holds a CPC certification with the American Academy of Professional Coders (AAPC).