Find comprehensive information on prostate cancer diagnosis including ICD-10 codes C61, N73.2, and related SNOMED CT concepts. Learn about Gleason score, PSA levels, DRE findings, transrectal ultrasound, biopsy procedures, and staging for accurate clinical documentation and medical coding. Explore healthcare resources for prostate cancer treatment, management, and prognosis. This resource supports physicians, coders, and healthcare professionals seeking accurate and efficient documentation of prostate cancer.
Also known as
Malignant neoplasm of prostate
Cancer originating in the prostate gland.
Primary malignant neoplasm
Identifies the prostate as the primary cancer site.
Personal history of prostate cancer
Indicates a past diagnosis of prostate cancer, now resolved.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the prostate cancer confirmed by pathology?
Yes
Is there metastasis?
No
Do not code prostate cancer. Code the signs/symptoms or reason for encounter.
When to use each related code
Description |
---|
Prostate cancer |
Benign prostatic hyperplasia |
Prostatitis |
Incomplete documentation of laterality (right, left, bilateral) for prostate cancer can lead to coding errors and inaccurate reporting.
Incorrect assignment or documentation of the Gleason score can impact risk stratification and treatment coding for prostate cancer.
Discrepancies between clinical staging and pathological staging of prostate cancer may result in incorrect coding and reimbursement issues.
Prostate cancer diagnosis confirmed in a [Age] year-old male patient presenting with [Symptoms, e.g., lower urinary tract symptoms, erectile dysfunction, back pain]. Digital rectal examination revealed [DRE findings, e.g., an enlarged, firm, or nodular prostate]. Prostate-specific antigen (PSA) level measured [PSA value] ngmL. Transrectal ultrasound (TRUS) guided biopsy of the prostate was performed, and histopathological analysis revealed [Gleason score] adenocarcinoma of the prostate. Staging workup, including bone scan and CT scan of the abdomen and pelvis, was conducted to assess the extent of disease and determine appropriate prostate cancer treatment. The TNM staging is currently [TNM stage]. Differential diagnoses considered included benign prostatic hyperplasia (BPH), prostatitis, and other urological conditions. Treatment options discussed with the patient include active surveillance, radical prostatectomy, radiation therapy (external beam radiation therapy or brachytherapy), hormone therapy (androgen deprivation therapy), and chemotherapy. Patient education regarding prostate cancer prognosis, side effects of treatment, and follow-up care was provided. Referral to urology and oncology for further management and shared decision-making regarding prostate cancer treatment plan. Medical coding will utilize ICD-10 code C61 for malignant neoplasm of the prostate and relevant CPT codes for procedures performed, including biopsy, imaging, and consultations. This documentation supports medical billing for services rendered. The patient will continue to be monitored for prostate cancer recurrence and treatment-related complications.