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Question: An elderly patient was complaining of frequent urination during their annual exam. They also mentioned noticing discoloration and darkening of their urine. Test results showed some trace amounts of blood in their urine sample. This patient has a history of enlarged prostate, so the physician ordered a prostate-specific antigen (PSA) screening to rule out prostate cancer. The PSA results came back within normal limits. How should I code this encounter?

Florida Subscriber

Answer: Due to the patient complaining of urinary frequency and hematuria, you鈥檒l report N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms). This code will cover the enlarged prostate and the patient鈥檚 hematuria. Code N40.1 also features a Use additional code note instructing you to report one of the listed codes if they apply to the patient鈥檚 symptoms. In your case, you鈥檒l also assign R35.0 (Frequency of micturition) to report the urination frequency.

Keep in mind: In the case where test results had shown an elevated PSA, your diagnosis coding would change to R97.20 (Elevated prostate specific antigen [PSA]). Also, if your urologist had specifically diagnosed prostate cancer, you would then report C61 (Malignant neoplasm of prostate) instead.

PSA defined: Your urologist requested a PSA test for diagnostic purposes to either confirm or exclude the presence of prostate cancer. This test quantifies the PSA levels in the patient鈥檚 blood, and a high level could suggest cancer. Therefore, you should select one of the subsequent diagnostic test codes for reporting:

• 84152 (Prostate specific antigen (PSA); complexed (direct measurement))
• 84153 (... total)
• 84154 (... free)

The complexed PSA test quantifies the PSA that is bound to proteins in the blood. On the other hand, the free diagnostic screening determines the amount of PSA that circulates freely without being attached to proteins. However, the most frequently used is the total screening, which quantifies both the bound and unbound PSA. It鈥檚 crucial to review your urologist鈥檚 documentation to ascertain which test they requested, ensuring you select the appropriate code.

Make note: For Medicare beneficiaries, there is a preventive medicine screening for prostate cancer. Eligible patients over 50 years of age are allowed a screening PSA and digital rectal exam to check for prostate cancer every 12 months. For these cases, report HCPCS Level II code G0102 (Prostate cancer screening; digital rectal examination) or G0103 (鈥� prostate specific antigen test (PSA)).

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC