Learn How to Assign R97.20 for Elevated PSA Values
Question: A 55-year-old patient presented to the urologist for a prostate specific antigen (PSA) screening. The urologist reviewed the results and documented, “elevated PSA level compared to the last screening,” and wanted to repeat the PSA test in six months. Is this enough information to warrant using R97.20 on the claim? South Dakota Subscriber Answer: You can assign R97.20 (Elevated prostate specific antigen [PSA]) to report the elevated PSA level. The physician documented that the PSA level increased, and that is the information you need to use to select your codes. Coders cannot assign a diagnosis code from a lab value, but the doctor documented their impression of the lab results. On the other hand, if the patient previously had prostate cancer and the PSA value was elevated following treatment of the malignancy, then you’d assign R97.21 (Rising PSA following treatment for malignant neoplasm of prostate). Mike Shaughnessy, BA, CPC, Production Editor, AAPC
