Summary & Overview
CPT 0113U: MiPS Prostate Score Molecular Diagnostic Test
CPT code 0113U designates the MiPS (Mi–Prostate Score) proprietary laboratory test from Mlabs, a molecular diagnostic assay that combines detection of TMPRSS2–ERG and PCA3 RNA with serum PSA to produce a prostate cancer risk score. As a PLA code, 0113U applies to a single manufacturer-specific test and informs payer coverage, coding consistency, and lab billing practices nationally. This code matters because proprietary molecular tests are increasingly used to refine prostate cancer risk assessment and influence downstream diagnostic and treatment decisions.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what 0113U represents clinically, typical sites of service, and the payer landscape. The publication outlines coverage considerations, common modifiers used with laboratory services, and where the MiPS test fits in diagnostic workflows. It also summarizes expected benchmarking and policy topics that affect PLA-coded assays, such as payer-specific medical necessity requirements and Medicare laboratory payment considerations.
This national-level summary is intended to help coding, billing, and policy teams quickly understand the clinical purpose of 0113U, the payer set most relevant to national coverage discussions, and the types of operational and policy details that influence reimbursement and utilization.
Billing Code Overview
CPT code 0113U is a Proprietary Laboratory Analyses (PLA) code for the MiPS (Mi–Prostate Score) test from Mlabs. The MiPS test uses RNA amplification and fluorescence labeling to detect two prostate cancer–associated genes, TMPRSS2–ERG and PCA3. These molecular results are combined with serum PSA level in a proprietary algorithm to generate a risk score for prostate cancer.
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Service type: Molecular diagnostic laboratory test that provides a risk score for prostate cancer using gene expression and serum PSA
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Typical site of service: Independent or hospital-associated clinical laboratory and outpatient specimen collection sites
Clinical & Coding Specifications
Clinical Context
A 62-year-old man with a rising prostate-specific antigen (PSA) level and prior elevated prostate cancer risk factors presents for prostate cancer risk assessment. The urologist orders the MiPS (Mi–Prostate Score) test (0113U) from Mlabs to improve decision-making about the need for prostate biopsy. A clinic visit documents history, digital rectal exam, and serum PSA result. A blood sample or urine sample is collected per the test's instructions and sent to the performing laboratory. The lab performs RNA amplification and fluorescence labeling to detect TMPRSS2–ERG and PCA3 expression, combines those molecular results with the serum PSA value in the proprietary algorithm, and returns a numerical risk score for clinically significant prostate cancer. The result is reviewed by the ordering provider during follow-up to guide shared decision-making about biopsy, imaging, or active surveillance.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Unmodified service | Rarely used; indicates no modifier applies when required by payer. |
11 | Primary service | When 0113U is the principal test performed for the encounter. |
26 | Professional component | When reporting the physician interpretation separate from the lab technical component (if applicable and allowed). |
52 | Reduced services | When ordered testing is partially performed or truncated. |
53 | Discontinued procedure | If specimen collection or testing was begun but discontinued for patient safety reasons. |
54 | Surgical care only | Not typically applicable; included if a surgical specialty bills only surgical care in an episode that also involved testing. |
55 | Postoperative management only | Not typically applicable; use when another provider bills postoperative care only. |
62 | Two surgeons | Uncommon; when two surgeons are involved in a procedure associated with the diagnostic pathway. |
78 | Unplanned return to OR | Not applicable to the lab test itself but available when related procedures require reoperation. |
80 | Assistant surgeon | Rarely applicable for this lab test; relevant if billed in a procedural episode. |
QK | Medical direction of 2–4 assistants | Not typically used for lab PLA codes; included for completeness. |
QX | Service performed by assistant surgeon (independent) | See notes above; rarely applicable. |
QY | Medical direction of one assistant | As above; uncommon for lab testing. |
TC | Technical component | Use when billing only the lab's technical component and the payer requires separation of TC/26 reporting for PLA codes. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207RH0000X | Urology | Urologists commonly order 0113U to assess prostate cancer risk. |
207L00000X | Pathology | Pathology/laboratory directors oversee test performance and result interpretation in the lab. |
208D00000X | Diagnostic Radiology | Radiologists may be involved in follow-up imaging decisions guided by the test result. |
363LP0800X | Clinical Laboratory | Clinical laboratory services perform the technical testing and reporting for 0113U. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
R97.20 | Elevated prostate specific antigen [PSA], unspecified | Elevated PSA is a primary indication for ordering 0113U to refine cancer risk assessment. |
R97.21 | Elevated prostate specific antigen [PSA], screened prostate specific antigen (PSA) | Screening-related elevated PSA prompting further molecular risk stratification with 0113U. |
N40.0 | Benign prostatic hyperplasia with lower urinary tract symptoms | BPH can raise PSA and confound risk assessment; 0113U may aid in distinguishing cancer-related risk. |
N45.1 | Spermatocele (example) | Not a typical indication; included to show non-malignant prostate-related diagnoses — use with caution. |
C61 | Malignant neoplasm of prostate | 0113U provides risk scoring that may support diagnosis and management decisions for prostate cancer. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
84153 | Prostate specific antigen (PSA); total | Serum PSA is used as an input to the MiPS algorithm and is typically measured before or concurrent with 0113U. |
83891 | Molecular pathology procedure, Level 1 (if applicable) | Represents simple molecular testing workflows; laboratories may bill molecular CPTs for ancillary testing components when permitted. |
88172 | Flow cytometry, interpretation | Not routinely used for MiPS; listed as an example of ancillary laboratory testing that can be performed in prostate cancer workup. |
88360 | Morphometric analysis (e.g., computerized) | May be used for pathology analyses on biopsy specimens obtained based on 0113U results. |
88305 | Level IV surgical pathology, gross and microscopic examination | Performed on prostate biopsy specimens when 0113U leads to biopsy; reflects tissue diagnostic workflow. |