- Preventive Services Guide
- Medicare Preventive Services Resource Guide
- Alcohol Misuse and Counseling
- Annual Wellness Visit Screening
- Bone Mass Measurements
- Cardiovascular Disease Screening Tests
- Colorectal Cancer Screening
- Counseling to Prevent Tobacco Use
- Depression Screening
- Diabetes Screening
- Diabetes Self-Management Training
- Glaucoma Screening
- Hepatitis B Virus Screening
- Hepatitis B Virus Vaccine and Administration
- Hepatitis C Virus Screening
- Human Immunodeficiency Virus Screening
- Influenza Virus Vaccine and Administration
- Initial Preventive Physical Examination
- Intensive Behavioral Therapy for Cardiovascular Disease
- Intensive Behavioral Therapy for Obesity
- Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low-Dose Computed Tomography
- Medical Nutrition Therapy
- Pneumococcal Vaccine and Administration
- Prolonged Preventive Services
- Prostate Cancer Screening
- Screening for Cervical Cancer with Human Papillomavirus Tests
- Screening for Sexually Transmitted Infections and HIBC to Prevent STIs
- Screening Mammography
- Screening Pap Tests
- Screening Pelvic Examinations
- Ultrasound Screening for Abdominal Aortic Aneurysm
- Vaccinations
- Related Articles
- Medicare Preventive Services Resource Guide
- The Annual Wellness Visit
- Medicare’s Annual Wellness Visit in Illinois: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Minnesota: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Wisconsin: Understanding the Benefit and Preventing Denials
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
- MPFS: Fee Schedule Lookup
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
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 50
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 4, Section 210.1
- MLN® Educational Tool: Medicare Preventive Services
Revised 10/12/2023