Oncology & Hematology Coding Alert
Know Cancer History Before Choosing PSA Dx
Question: We perform our own diagnostic PSA tests for patients who have benign prostatic hyperplasia, based on urinary symptoms. Which diagnosis code(s) should we use for the test results? Codify Subscriber Answer: If the physician confirms an elevated prostate specific antigen (PSA), you should report R97.20 (Elevated prostate specific antigen [PSA]). Normal PSA is different: On the other hand, if the physician notes the PSA findings are normal, you should report the reason for the test, which is benign prostatic hypertrophy (BPH). Based on the urinary symptoms, the proper code in this case would be N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms). You should report additional codes to identify symptoms, according to ICD-10 instruction. For this case, you would list R33.8 (Other retention of urine) and R35.0 (Frequency of micturition). Different code applies to cancer history: If the patient has a history of prostate cancer and is found to have an elevated PSA, report R97.21 (Rising PSA following treatment for malignant neoplasm of prostate).
Oncology & Hematology Coding Alert
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Know Cancer History Before Choosing PSA Dx
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