Understanding PSA testing diagnosis codes? Find information on prostate-specific antigen (PSA) test interpretation, normal PSA levels, elevated PSA levels, PSA test medical coding (ICD-10, CPT codes), and clinical documentation requirements for accurate healthcare reimbursement. Learn about PSA screening, prostate cancer diagnosis, and the role of PSA testing in preventative healthcare.
Also known as
Encounter for screening for prostate cancer
Includes PSA testing for prostate cancer screening.
Abnormal findings on prostate exam
May include elevated PSA levels requiring further investigation.
Encntr for exam of male genital organs
May include PSA testing as part of a general male genital exam.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is PSA test for screening?
Yes
Code Z12.5 Encounter for screening for malignant neoplasm of prostate
No
Is PSA test for monitoring?
When to use each related code
| Description |
|---|
| Prostate cancer screening |
| Benign prostatic hyperplasia (BPH) |
| Prostatitis (inflammation) |
Coding with unspecified PSA test code when a more specific code is documented, leading to underpayment and data inaccuracies. Medical coding, CDI, healthcare compliance.
Mismatched PSA test result and documented diagnosis (e.g., benign prostatic hyperplasia vs. prostate cancer). Medical coding, CDI, healthcare compliance audit.
Lack of documentation supporting the medical necessity of the PSA test, resulting in claim denials. Healthcare compliance, medical coding audit, CDI specialist.
Patient presents for prostate-specific antigen (PSA) testing. Discussion regarding prostate cancer screening, including risks and benefits, was conducted. Patient's age, family history of prostate cancer, ethnicity, and any prior PSA results were considered. Digital rectal exam (DRE) findings, if performed, are documented separately. Reason for PSA test includes routine screening, elevated prior PSA, or monitoring after prostate cancer treatment. The patient understands the implications of an elevated PSA level and the potential need for further evaluation, such as prostate biopsy, if indicated. Venipuncture was performed for PSA blood draw. Lab results are pending. Patient education provided on PSA test interpretation, prostate health, and follow-up recommendations. ICD-10 code Z12.5 (Encounter for screening for malignant neoplasm of prostate) is appropriate for routine screening. Appropriate diagnosis codes for abnormal results or follow-up will be assigned upon receipt and interpretation of lab data. CPT code 84153 is applicable for the quantitative PSA test. The patient will be notified of the results and scheduled for follow-up as necessary.