Patient presents with a history of prostate carcinoma.  Initial diagnosis of prostate cancer was established on [Date of original diagnosis] based on [Diagnostic method, e.g., biopsy findings showing adenocarcinoma, Gleason score X].  The patient's original prostate cancer treatment included [Treatment details, e.g., radical prostatectomy, radiation therapy, brachytherapy, androgen deprivation therapy].  Current presentation includes [Reason for visit, e.g., routine follow-up, rising PSA, new onset bone pain].  Physical exam reveals [Relevant findings, e.g., normal rectal exam, palpable lymph nodes].  Prostate-specific antigen (PSA) level is currently [PSA value with units and date].  Imaging studies including [Imaging modality and date, e.g., bone scan, CT scan, MRI] show [Imaging findings, e.g., no evidence of recurrent disease, suspicious lesion in bone].  Assessment: History of prostate cancer, now [Status, e.g., in remission, with biochemical recurrence, metastatic].  Plan includes [Plan of care, e.g., continued surveillance with PSA testing, imaging studies, referral to medical oncology, initiation of hormonal therapy]. Differential diagnoses at initial presentation included benign prostatic hyperplasia (BPH) and prostatitis.  Coding considerations include ICD-10 code Z85.820 (Personal history of malignant neoplasm of prostate) and relevant codes for current symptoms, treatment, and surveillance.  Medical billing should reflect evaluation and management (E M) services as well as any procedures performed.