prostate recurrence after prostatectomy

KMayercsik

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I know I read this information but can't remember.
We have a patient that had prostatectomy, and now rising PSA after radiation.
Does this get coded as an active prostate C61, R97.21. Z79.90. I think I read that it is treated as active disease.
 

thomas7331

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I know I read this information but can't remember.
We have a patient that had prostatectomy, and now rising PSA after radiation.
Does this get coded as an active prostate C61, R97.21. Z79.90. I think I read that it is treated as active disease.
You can't assign code C61 from this information alone - you'd need to have the provider's documented assessment of the status of the malignancy to determine the correct coding.
 

trarut

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Rising PSA can be indicative of recurrence but is not definitive proof. You really can't code more than the rising PSA, history of radiation and history of prostate cancer based on what you have provided. I would add a caveat that depending on where you work, some facilities will define the time period for active v. historical disease so I would refer to that guideline if it exists. If it's been just a short period of time since the patient had surgery and radiation, the primary disease may well still be considered active and reportable with C61. Your best bet is to check your organization's coding guidelines and query the provider for clarification if necessary.
 
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