Look to Provider Documentation to Code Elevated PSA
Question: A patient’s prostate-specific antigen (PSA) test showed a level that was higher than their baseline and the previous screening value, but the level is not above the absolute normal range. Does this mean the patient’s PSA level is elevated, even if it’s technically within the generally accepted normal range for all patients, and we can document R97.20? In other words, does “elevated” mean compared to the patient’s own individual levels or only elevated per the normal range? AAPC Forum Participant Answer: The National Cancer Institute believes “there is no single threshold that distinguishes a normal versus an abnormal PSA result.” It goes on to state “this is in part because there is no specific PSA level that means that someone has prostate cancer.” This also means the term “elevated” is somewhat subjective and based on provider documentation. So, if the word appears in the medical record, whether the provider has based it on the patient’s baseline, previous PSA results, or some other criteria, you would be justified in using R97.20 (Elevated prostate specific antigen [PSA]). However, if the patient has previously had prostate cancer, a more appropriate code to use for a patient’s elevated PSA level with R97.21 (Rising PSA following treatment for malignant neoplasm of prostate). The term “rising” can be interpreted as “elevated” in this situation. Remember: As a coder, you should never code from lab values. Instead, you should assign a code based on a provider’s documented impression of the lab value. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
