Elevated prostate specific antigen [PSA]
ICD-10 R97.20 is a billable code used to indicate a diagnosis of elevated prostate specific antigen [psa].
Elevated prostate specific antigen (PSA) is a laboratory finding indicating higher than normal levels of PSA in the blood, which is a protein produced by both normal and malignant cells of the prostate gland. Elevated PSA levels can be indicative of various prostate conditions, including benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer. The normal range for PSA levels varies, but generally, levels above 4 ng/mL are considered elevated. However, age, race, and family history can influence these thresholds. Elevated PSA is not a definitive diagnosis but rather a signal for further investigation, which may include digital rectal examination (DRE), imaging studies, or prostate biopsy. Clinicians must interpret PSA results in the context of the patient's overall clinical picture, including symptoms such as urinary difficulties, pelvic pain, or changes in urinary habits. The management of elevated PSA levels often involves monitoring and may lead to referrals to urology for further evaluation.
Documentation should include patient history, clinical findings, and rationale for PSA testing.
Routine screening in asymptomatic patients, evaluation of urinary symptoms.
Consideration of patient age and risk factors when interpreting PSA levels.
Acute care documentation should detail presenting symptoms and any immediate interventions.
Patients presenting with acute urinary retention or severe pelvic pain.
Rapid assessment of PSA levels in the context of acute presentations.
Used when PSA testing is performed as part of routine screening or evaluation.
Document the reason for the PSA test and any relevant clinical findings.
Urologists may order PSA tests more frequently for monitoring.
An elevated PSA level may indicate prostate conditions such as benign prostatic hyperplasia, prostatitis, or prostate cancer, but further evaluation is necessary to determine the cause.
