2025 ICD-10-CM code R97.21
Rising PSA following treatment for malignant neoplasm of prostate.
Medical necessity for further investigation and management is based on the rising PSA level and the patient's overall clinical picture.
It is the clinician's responsibility to accurately interpret the PSA results in the context of the patient's medical history, treatment, and other relevant clinical findings.The rising PSA should be investigated to determine the cause and appropriate management strategy.
- 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- R97-R97.8 Abnormal tumor markers
In simple words: This code indicates a rising Prostate-Specific Antigen (PSA) level after treatment for prostate cancer.
Rising PSA following treatment for malignant neoplasm of prostate. This code indicates an increase in prostate-specific antigen (PSA) levels in a patient who has previously undergone treatment for prostate cancer.It is used to monitor for recurrence or progression of the disease.
Example 1: A 65-year-old male patient who underwent radical prostatectomy for prostate cancer two years ago presents for follow-up.His PSA level has risen from undetectable to 0.2 ng/mL. Code R97.21 is used to document the rising PSA., A 70-year-old male patient who completed radiation therapy for prostate cancer five years ago has a steadily rising PSA over the past year.Code R97.21 is assigned to reflect this finding., A 75-year-old male patient with a history of prostate cancer treated with brachytherapy experiences a rise in PSA levels after being in remission for several years.R97.21 is used to document the rising PSA and the need for further investigation.
Documentation should include the patient's prior treatment for prostate cancer, the current PSA level, the trend of PSA levels over time, and any other relevant clinical findings.
** The code R97.21 does not specify the underlying cause of the rising PSA, which may include recurrence of prostate cancer, benign prostatic hyperplasia, prostatitis, or other factors. Further investigation is needed to determine the cause and appropriate management.
- Specialties:Urology, Oncology
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital