Elevated prostate specific antigen [PSA]
ICD-10 R97.2 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. It is important to note that elevated PSA does not confirm cancer; further diagnostic evaluation, including digital rectal examination (DRE), imaging studies, and possibly biopsy, is often required to determine the underlying cause. Clinicians must consider patient history, age, and other risk factors when interpreting PSA levels. The clinical context surrounding elevated PSA is critical, as it may lead to further investigation or monitoring rather than immediate intervention.
Thorough documentation of patient history, risk factors, and clinical findings related to PSA testing.
Routine screening in asymptomatic patients, evaluation of urinary symptoms, and monitoring of known prostate conditions.
Consideration of age-specific PSA thresholds and the need for shared decision-making with patients regarding further testing.
Clear documentation of acute symptoms prompting PSA testing, including any relevant history of prostate issues.
Patients presenting with acute urinary retention or severe pelvic pain.
Rapid assessment of PSA levels in the context of acute presentations, with appropriate follow-up plans.
Used for routine screening or evaluation of prostate conditions.
Document the reason for PSA testing and any relevant clinical findings.
In urology, PSA testing is often part of a comprehensive prostate evaluation.
An elevated PSA level may indicate prostate cancer, benign prostatic hyperplasia, or prostatitis. Further evaluation is necessary to determine the underlying cause.
The frequency of PSA testing depends on individual risk factors, including age, family history, and previous PSA levels. Discuss with a healthcare provider for personalized recommendations.
