Understand PSA screening, prostate cancer screening, and prostate-specific antigen testing with this guide. Learn about normal PSA levels, elevated PSA results, PSA test codes (CPT codes), ICD-10 codes for abnormal PSA, and the role of digital rectal examination (DRE) in prostate health. This resource covers healthcare documentation best practices for PSA screening, including medical necessity documentation and billing guidelines. Find information on prostate cancer diagnosis, prostate biopsies, and the importance of early detection through routine screenings.
Also known as
Encounter for screening for prostate cancer
Examination for early detection of prostate cancer.
Abnormal findings on screening for prostate cancer
Suspicious results from prostate cancer screening tests.
Encounter for examination of male genital organs
General check-up including the prostate.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the PSA screening for a specific medical condition?
Yes
Is it for prostate cancer surveillance?
No
Is it routine screening?
When to use each related code
| Description |
|---|
| PSA Screening |
| Elevated PSA |
| Benign Prostatic Hyperplasia (BPH) |
Coding with unspecified PSA screening codes when a more specific code is documented, impacting reimbursement and data accuracy.
Lack of documentation supporting medical necessity for PSA screening, leading to denials and compliance issues. Focus on ICD-10-CM coding accuracy.
Incorrect coding for frequency of PSA screening, resulting in overbilling or underreporting. CDI review crucial for compliant CPT coding.
Patient presents for prostate-specific antigen (PSA) screening. Discussion regarding the benefits and limitations of PSA testing, including the potential for false positives and negatives, was conducted. Patient's age, family history of prostate cancer, ethnicity, and prior PSA levels, if applicable, were reviewed and documented. Digital rectal exam (DRE) findings, if performed, are noted separately. Patient understands the implications of an elevated PSA result and the potential need for further evaluation, such as a prostate biopsy. Order placed for total PSA laboratory testing. Patient education provided on prostate cancer risk factors, early detection, and treatment options. Follow-up appointment scheduled to review PSA results and discuss next steps based on findings. ICD-10 code Z12.5 (encounter for screening for malignant neoplasm of prostate) is applicable. CPT code 86316 (prostate specific antigen; total) will be billed for the laboratory test. Patient verbalized understanding of the procedure and plan.