Understand Screening PSA diagnosis, medical coding, and clinical documentation best practices. Find information on PSA test interpretation, normal PSA levels, elevated PSA levels, prostate cancer screening guidelines, and appropriate ICD-10 codes for abnormal PSA findings. This resource helps healthcare professionals ensure accurate and comprehensive documentation for improved patient care and billing compliance related to prostate-specific antigen screening.
Also known as
Encounter for screening for prostate cancer
Covers examinations specifically for early prostate cancer detection.
Person with potential health hazards related to family
May be used if family history prompts PSA screening.
Encntr for prostatic spec exam w abnormal find
Use if PSA test is part of a broader prostate exam with unusual results.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the PSA screening for prostate cancer?
Yes
Is there a personal history of prostate cancer?
No
Do not code as screening PSA. Review documentation for alternative diagnosis.
When to use each related code
| Description |
|---|
| Screening PSA |
| Elevated PSA |
| Abnormal DRE |
Coding lacks specificity (e.g., total, free, complexed) impacting medical necessity reviews and reimbursement.
PSA screening assigned without documented suspicion or family history, triggering audits for medical necessity.
Incorrect or missing modifiers (e.g., frequency, medical necessity) leading to claim denials and compliance issues.
Patient presents for prostate cancer screening with a prostate-specific antigen (PSA) test. Discussion regarding the benefits, risks, and limitations of PSA screening, including the possibility of false positives, false negatives, and overdiagnosis, was conducted. Patient's age, family history of prostate cancer, ethnicity, and prior PSA levels, if applicable, were considered in the risk assessment. Digital rectal exam (DRE) findings, if performed, are documented separately. This screening PSA test is ordered as part of preventative healthcare and is not indicated for diagnostic evaluation of existing prostate-related symptoms. Patient understands the implications of an elevated PSA level and the need for further evaluation, potentially including a prostate biopsy, depending on the result. Pre-test probability for prostate cancer was assessed based on clinical risk factors. Patient education provided regarding the potential need for follow-up based on the PSA result. This encounter is coded for screening for malignant neoplasm of the prostate.