tci Medicare Compliance & Reimbursement - 2023 Issue Q3

Reader Questions: Know These Important Facts on PSA Tests for Screening or Diagnosis

Question: A 66-year-old male patient was complaining of frequent urination during his annual physical. He also noticed some discoloration and darkening of his urine, and test results showed some trace blood in his urine. He has a history of enlarged prostate, and the physician ordered a prostate-specific antigen (PSA) screening to rule out prostate cancer, which came back within normal limits. What diagnosis code should I use for this encounter? What test code should I report? AAPC Forum Participant Answer: Because the patient reported some urinary frequency and hematuria, you’ll report N40.1 (Benign prostatic hyperplasia with lower...

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