Patient presents for prostate cancer screening.  Risk factors discussed included age, family history of prostate cancer, and ethnicity.  Patient reports no urinary symptoms such as frequency, urgency, hesitancy, nocturia, weak stream, straining, or hematuria.  Digital rectal examination (DRE) findings were documented.  Prostate-specific antigen (PSA) test ordered and reviewed.  Shared decision-making regarding prostate cancer screening benefits and risks, including false positives, overdiagnosis, and potential complications of biopsy and treatment, was conducted.  Patient understands the implications of an elevated PSA level and the need for further evaluation, including prostate biopsy, if indicated.  Plan for follow-up and monitoring based on PSA results and clinical presentation.  ICD-10 code Z12.5 (Encounter for screening for malignant neoplasm of prostate) assigned. CPT code for the appropriate level of Evaluation and Management (E/M) service documented. This documentation supports medical necessity for prostate cancer screening.

Patient presents with a family history of prostate cancer and is concerned about his risk.  He denies any lower urinary tract symptoms (LUTS) including hesitancy, dribbling, weak stream, or pain with urination.  A digital rectal exam (DRE) was performed, and the prostate was noted to be of normal size and consistency without palpable nodules or induration.  Prostate specific antigen (PSA) testing was discussed, and the patient elected to proceed with the test.  Pre-test counseling included a discussion of the sensitivity and specificity of PSA testing, the possibility of false positive results, and the need for further evaluation if the PSA is elevated.  ICD-10 code Z12.5 assigned. CPT code for counseling and risk assessment documented.  Results of PSA testing will be discussed with the patient at a follow-up appointment.  Plan for shared decision making regarding further evaluation and management based on PSA results and individual patient preferences.

Patient presents for follow-up of elevated PSA.  Previous PSA result was documented.  Discussion regarding potential causes of elevated PSA, including benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer, was conducted.  Patient's medical history, family history, and prior screening results reviewed.  Options for further evaluation, including repeat PSA testing, free PSA, PSA velocity, and prostate biopsy, discussed with the patient.  Risks and benefits of each option, including potential complications, were explained.  Patient expressed understanding and preference for repeat PSA testing and free PSA.  ICD-10 code R97.2 (Abnormal findings on examination of prostate) assigned. CPT code for the appropriate E/M service documented.  Follow-up appointment scheduled to review results and discuss further management if indicated.