What ICD‑10‑CM code is used for a routine prostate‑specific antigen (PSA) screening in an asymptomatic adult male, and which code should be added if the PSA result is elevated?

ICD-10-CM Coding for PSA Screening

For routine PSA screening in an asymptomatic adult male, use Z12.5 (Encounter for screening for malignant neoplasm of prostate). If the PSA result is elevated, add R97.20 (Elevated prostate specific antigen [PSA]).

Primary Screening Code

• Z12.5 is the appropriate ICD-10-CM code for routine prostate cancer screening via PSA test in asymptomatic men 1, 2
• This code applies when the patient has no symptoms and is presenting specifically for cancer screening purposes 1
• The screening should follow shared decision-making, particularly for men aged 55-69 years with at least 10-15 years life expectancy 1

Code for Elevated PSA Result

• R97.20 (Elevated prostate specific antigen [PSA]) should be added when the PSA result is abnormal 3, 2
• This code is used regardless of the specific PSA value, whether it falls in the "gray zone" (4-10 ng/mL) or is significantly elevated (>10 ng/mL) 3, 2
• PSA levels >4.0 ng/mL are generally considered elevated and warrant further investigation 3, 2

Additional Coding Considerations

When Symptoms Are Present

• If the patient has lower urinary tract symptoms, erectile dysfunction, pain, hematuria, or other prostate-related symptoms, do not use Z12.5 1
• Instead, code the specific symptom (e.g., R33.8 for urinary retention, R31.9 for hematuria) as the primary diagnosis 1

Risk Stratification Context

• For high-risk patients (African-Americans, strong family history), Z12.5 remains appropriate for screening, but consider adding Z80.42 (Family history of malignant neoplasm of prostate) if applicable 1
• PSA density >0.15 ng/mL/cc is a strong predictor of clinically significant cancer and may influence clinical decision-making, though it doesn't change the screening code 1, 3

Common Pitfalls to Avoid

• Don't use Z12.5 if the patient is symptomatic – screening codes are only for asymptomatic individuals 1
• Don't forget to add R97.20 when PSA is elevated – this documents the abnormal finding and justifies further workup 3, 2
• Don't use cancer diagnosis codes (C61) unless biopsy-confirmed – elevated PSA alone does not equal cancer, as approximately 2 of 3 men with elevated PSA do not have prostate cancer 3, 2
• Avoid testing during active UTI or prostatitis – these conditions can falsely elevate PSA and should be coded separately (N39.0 for UTI, N41.x for prostatitis) 2, 4
• Remember that 5α-reductase inhibitors reduce PSA by approximately 50% – this clinical context matters for interpretation but doesn't change the coding 3, 2