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Pathology/Lab Coding Alert

Reader questions:

Focus on PSA Results

Published on Sun Sep 12, 2010

Question: A physician orders a diagnostic PSA test for a patient diagnosed with BPH based on urinary retention and frequency. The lab finds elevated PSA levels. What diagnosis code(s) should we use for the test?Ohio SubscriberAnswer: If you find elevated prostate specific antigen (PSA), you should report the diagnosis code that supports those findings -- 790.93 (Elevated prostate specific antigen [PSA]).Normal PSA is different: On the other hand, if the PSA findings were normal, you should report the reason for the test -- benign prostatic hypertrophy (BPH). Based on the urinary symptoms, the proper code in this case would be 600.01(Hypertrophy, benign of prostate with urinary obstruction and other lower urinary tract symptoms). You should report additional codes to identify symptoms, according to ICD-9 instruction. For this case, you would list 788.20 (Retention of urine, unspecified) and 788.41 (Urinary frequency).Don't forget cancer history: If the patient has a history of prostate cancer, [...]
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