Urology Coding Alert

Question: A positive prostate biopsy led to a patient being diagnosed with prostate cancer in 2012. The biopsy showed a 1mm adenocarcinoma in 1 of 5 cores on right side, left side negative. The patient opted for watchful waiting instead of going through treatment (surgery, radiation, etc.). At a recent check-up, his PSA was elevated to 13.65, up from 10 at the time of his previous biopsy. The urologist performed another prostate biopsy to see if there was progression of the disease. The pathology report came back negative for all cores. Do I still use prostate cancer as a primary diagnosis with elevated PSA as secondary? Will Medicare question the repeat biopsy if the patient already has a diagnosis of prostate cancer?

Pennsylvania Subscriber

Answer: You should still use C61 (Malignant neoplasm of prostate) as a diagnosis for the prostate biopsy. The cancer was not treated and is still present although the recent biopsies apparently missed the tumor. However, the patient still has prostate cancer. You may also use as R97.21 (Rising PSA following treatment for malignant neoplasm of prostate) as a secondary diagnosis since watchful waiting is also considered a treatment modality.

It’s unlikely that Medicare will question the repeat biopsy since the urologist performed it to evaluate the progression of disease in a patient under watchful waiting.