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Question: We have a patient that had prostatectomy, and their prostate-specific antigen (PSA) levels are now rising after radiation. How is this coded? Is the active prostate treated as active cancer?

AAPC Forum Participant

Answer: Based on the information you have provided, you can probably only code R97.21 (Rising PSA following treatment for malignant neoplasm of prostate) with Z85.46 (Personal history of malignant neoplasm of prostate) and Z92.3 (Personal history of irradiation) in this particular scenario. As described, the scenario does not suggest a definitive diagnosis of a returning prostate cancer, despite the rising PSA levels, so you should not assign C61 (Malignant neoplasm of prostate) for this encounter.

However, you should check your organization’s guidelines regarding the classification of the prostate cancer being active or historic. If the patient only recently underwent the surgery and radiation for the prostate cancer, it is possible your organization may regard it as still active, and coding C61 may be appropriate. In addition to rechecking the guidelines, querying the provider to clarify would also be advisable in this case.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC