What is the ICD-10 (International Classification of Diseases, 10th Revision) code for a patient experiencing urinary retention (Retention of urine) and seeking a Prostate-Specific Antigen (PSA) check?

ICD-10 Coding for Difficulty Initiating Urination with PSA Testing

For a patient experiencing difficulty starting urination (hesitancy), use ICD-10 code R39.11 (Hesitancy of micturition) or R33.8 (Other retention of urine) if there is incomplete bladder emptying, and code Z13.89 (Encounter for screening for other disorder) or Z01.419 (Encounter for gynecological examination without abnormal findings) for the PSA screening component. 1

Primary Symptom Coding

The specific voiding symptom should be coded based on clinical presentation:

• R39.11 - Hesitancy of micturition (difficulty getting started) 1
• R39.12 - Poor urinary stream (weak stream once started) 1
• R33.8 - Other retention of urine (if there is incomplete emptying or elevated post-void residual) 1
• R33.9 - Retention of urine, unspecified (if acute retention develops) 1

The symptom assessment should include evaluation of both storage symptoms (frequency, nocturia, urgency) and voiding symptoms (incomplete emptying, intermittency, straining, weak stream, hesitancy) using standardized questionnaires like the I-PSS. 1

Coding for PSA Testing Indication

The indication for PSA testing must be clearly documented:

• Z13.89 - Encounter for screening for other disorder (if PSA is for prostate cancer screening in asymptomatic context) 1
• N40.1 - Benign prostatic hyperplasia with lower urinary tract symptoms (if enlarged prostate is documented on DRE) 1
• R97.20 - Elevated prostate specific antigen (if following up abnormal PSA) 1

Clinical Context for PSA Testing

PSA testing should only be performed after shared decision-making and when life expectancy exceeds 10 years, as the diagnosis would need to modify management approach. 1

Key considerations for PSA testing in this context:

• Serum PSA is a reasonable predictor of prostate volume in men with lower urinary tract symptoms and can be used for clinical decision-making. 1
• Benefits and risks must be discussed, including false-positive/false-negative results, biopsy complications, and possibility of detecting clinically insignificant cancer. 1
• PSA testing is generally recommended for men 50 years and older with reasonable 10-year life expectancy, or starting at age 45 for African Americans and those with family history. 1

Important Caveats for Acute Retention

If the patient has acute urinary retention requiring catheterization, PSA testing should be delayed for at least 2 weeks, as acute retention causes temporary PSA elevation that reduces test accuracy. 2

• Acute urinary retention significantly elevates PSA levels, with only 28% of patients having PSA ≤4.0 ng/mL at presentation. 2
• Even with a cut-off of 20 ng/mL, the positive predictive value for prostate cancer is only 21% during acute retention. 2
• PSA has a half-life of 2-3 days, so waiting 2 weeks after catheterization allows normalization. 2
• Higher baseline PSA levels (>1.4 ng/mL) and larger prostate volumes (>40 mL) predict increased risk of developing acute urinary retention. 3, 4

Additional Diagnostic Codes to Consider

If digital rectal examination reveals prostate enlargement:

• N40.0 - Benign prostatic hyperplasia without lower urinary tract symptoms 1
• N40.1 - Benign prostatic hyperplasia with lower urinary tract symptoms 1

If hematuria is present, additional evaluation is mandatory regardless of PSA level, using code R31.9 (Hematuria, unspecified) and requiring cystoscopy to rule out bladder pathology. 5