Elevated prostate specific antigen [PSA]

This code indicates an abnormal laboratory finding of an elevated prostate-specific antigen level in the blood. It signifies a biochemical marker that may suggest the presence of prostate disease, including benign prostatic hyperplasia, prostatitis, or prostate cancer, but is not diagnostic of any specific condition.

Assign this code when documentation explicitly states an elevated PSA without a definitive diagnosis of a prostate condition. This is commonly used when a patient presents for follow-up of an abnormal lab result, or when the elevated PSA is an incidental finding during routine screening.

• Do not use this code if a definitive diagnosis for the elevated PSA (e.g., prostate cancer, BPH) has been established.
• This code is often a primary diagnosis when the patient is being worked up for the elevated PSA.
• Ensure the medical record clearly documents the elevated PSA value and that no definitive diagnosis has been made.