ICD-10 Code for Elevated PSA
The ICD-10 code for an elevated prostate-specific antigen (PSA) level is R97.20 (Elevated prostate specific antigen [PSA]).
Primary Coding
- R97.20 is the specific code for elevated PSA and should be used when documenting an abnormal PSA test result in adult male patients 1
Related ICD-10 Codes You May Need
Z12.5 - Encounter for screening for malignant neoplasm of prostate (use this when the PSA test is performed as part of routine prostate cancer screening) 1
N40.0 - Benign prostatic hyperplasia without lower urinary tract symptoms (if BPH is contributing to PSA elevation) 2
C61 - Malignant neoplasm of prostate (use only after biopsy-confirmed prostate cancer diagnosis) 2
Z85.46 - Personal history of malignant neoplasm of prostate (for post-treatment PSA monitoring) 2, 1
Clinical Context for Coding
Approximately 30-35% of men with PSA between 4-10 ng/mL will have cancer on biopsy, while two-thirds of elevated PSA values are due to benign conditions like BPH 2
When PSA is >50 ng/mL, the positive predictive value for prostate cancer is 98.5%, which may influence your diagnostic coding approach 3
For post-treatment monitoring, use R97.20 in conjunction with Z85.46 when PSA rises after radical prostatectomy (≥0.4 ng/dL) or radiation therapy (>1.5 ng/dL above nadir) 1
Documentation Tips
Always document the actual PSA value in ng/mL alongside the ICD-10 code, as this affects clinical decision-making and risk stratification 2
Note any confounding factors such as recent prostate manipulation, active UTI, or use of 5-alpha reductase inhibitors (finasteride/dutasteride), which can affect PSA levels and may require additional coding 1
Include PSA velocity if available (≥1.0 ng/mL per year is significant), as this may warrant additional diagnostic codes even with "normal" absolute PSA values 1