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Test Code PSA (Diag)/PSCRN (Screen) Prostate-Specific Antigen (PSA), serum

Performing Laboratory

MaineGeneral Medical Center

Reference Values

0-4.0 ng/mL

Specimen Requirements

This test may require an advanced beneficiary notice.

Draw blood in a serum gel tube(s). For pediatric specimen, draw blood in a red-top MICROTAINER(S)®. Spin down and send 1 mL of serum refrigerated.

Note:  1. Specimen should be drawn prior to prostatic/rectal examination or 24 to 48 hours after examination.

2. Label specimen with patient’s name (first and last), date of birth, date and time of draw, and phlebotomist’s initials.

Samples may be stored at 2-8C for up to forty-eight (48) hours. Do NOT use samples that have been stored at room temperature for greater than eight (8) hours. Freeze for longer storage.

Day(s) Test Set Up

Monday through Friday

Test Classification and CPT Coding

G0103 - PSA screening (Z12.5)

84153 - PSA diagnostic

Note:  This test, when ordered on Medicare patients, is subject to the CMS Medicare Coverage Issues Manual (MCIM), Diagnostic Services policy “Prostate Specific Antigen (Diagnostic).”  Please verify that the diagnosis code (ICD-10) you have chosen demonstrates medical necessity for the test as documented in the physician’s patient record. A properly executed Advance Beneficiary Notice (ABN) must be submitted with the specimen if medical necessity is not demonstrated by the ICD-10 code chosen.

Methodology

Chemiluminescent Immunoassay