When to Use and not use PSA R97.20 with examples

A patient walks out of the door after their annual physical. The lab work later comes back, and one value is flagged in red: an elevated Prostate Specific Antigen, or PSA. For the clinician, this result triggers a process of clinical decision-making. For the medical coder, however, it triggers a different kind of question: what is the accurate ICD-10 code for elevated prostate specific antigen to represent this finding?

Using the wrong code can seem like a minor clerical error, but in the world of medical billing, it can lead to immediate claim denials, delayed reimbursements, and even compliance red flags. After years of specializing in cardiology and urology coding, I have seen firsthand how a precise understanding of this specific scenario separates proficient coders from exceptional ones.

This guide will provide absolute clarity on the correct ICD-10 code for elevated prostate specific antigen. We will explore its official definition, navigate common coding pitfalls, and outline the documentation you need from providers to support your coding choices with confidence.

The Official ICD-10 Code for Elevated PSA

The ICD-10-CM code for an elevated PSA level without a confirmed diagnosis is R97.20.

Let’s break down this code to understand its full meaning:

• Category R97: This category is titled “Abnormal tumor markers.” Tumor markers are substances, often proteins, that can be measured in the blood and may indicate the presence of a malignancy.

• Code R97.2: This subcategory is specifically for “Elevated prostate specific antigen [PSA].”

• Code R97.20: This is the billable, specific code for “Elevated prostate specific antigen [PSA].” The ‘0’ as the fifth digit indicates that the elevated PSA is not linked to a prior diagnosis of prostate cancer. It is the default and most commonly used code for a new, asymptomatic finding of a high PSA.

The R97.20 code exists for a crucial reason: to report a significant laboratory finding that requires further investigation. It is a symptom or a sign, not a final diagnosis. Think of it as a red flag that prompts the physician to ask, “Why is this elevated?”

When to Use R97.20: Clinical Scenarios and Applications

Understanding the context for using this code is just as important as knowing the code itself. You should assign R97.20 when the medical record clearly indicates an elevated PSA level is the reason for a service, and no definitive diagnosis for the elevation has been established.

Consider these common scenarios where R97.20 is the correct choice:

Routine Screening with an Abnormal Result
A 55-year-old male undergoes a preventative health visit. His PSA test returns elevated at 6.5 ng/mL (with a normal range typically under 4.0). The physician orders a repeat test in six weeks to confirm the finding. For the repeat test, the diagnosis code is R97.20.

Monitoring a Patient with a History of Elevated PSA
A patient has a known history of benign prostatic hyperplasia (BPH) and has had borderline PSA levels in the past. His physician regularly checks his PSA as part of his ongoing management. The code for the monitoring PSA test, when the level is elevated, remains R97.20 unless a new, definitive diagnosis is made.

Presenting Symptom for a Specialist Consultation
A primary care physician detects an elevated PSA and refers the patient to a urologist for further evaluation. The primary care provider may use R97.20 as the reason for referral. The urologist will also use R97.20 for their initial consultation to investigate the cause of the elevation.

The consistent thread here is the absence of a confirmed cause. The code R97.20 effectively communicates to the payer: “We are performing this service to investigate an abnormal lab value.”

Critical Coding Pitfalls: What R97.20 is NOT For

Perhaps the most vital part of mastering this code is knowing when not to use it. Misapplication is a fast track to claim rejection. Here are the key distinctions every coder must memorize.

Do Not Use R97.20 for a Confirmed Cancer Diagnosis
This is the most significant and costly error. If the patient has a confirmed diagnosis of prostate cancer, you must use a code from the C61 series (Malignant neoplasm of prostate). Using R97.20 for a known cancer case is incorrect and will be denied, as the payer expects the definitive diagnosis code.

Do Not Use R97.20 for a History of Prostate Cancer
For a patient with a personal history of prostate cancer, whether in remission or actively being treated, you must use code Z85.46 (Personal history of malignant neoplasm of prostate). PSA tests for these patients are for surveillance of a known history, not for investigating a new, unexplained elevation.

Do Not Use R97.20 for Benign Prostatic Hyperplasia (BPH)
An elevated PSA can be a symptom of BPH, but if the provider has diagnosed the patient with BPH, that becomes the primary, billable diagnosis. You would use a code from the N40 series (Hyperplasia of prostate). The elevated PSA in this context is a clinical feature of BPH, not a separate, reportable finding.

The Power of Specificity: Documentation is Your Best Friend

Accurate coding hinges on precise documentation. The code R97.20 is powerful, but it requires clear support from the provider’s notes to be defensible.

When reviewing a chart, look for these key phrases that justify the use of R97.20:

• “Elevated PSA noted on screening lab work.”

• “Asymptomatic patient with PSA of 8.0, will re-check in 6 weeks.”

• “Referred to urology for evaluation of elevated PSA.”

• “PSA level is high, rule out underlying pathology.”

If the provider’s documentation only states “high PSA” or “elevated PSA,” you are on solid ground to use R97.20. However, if the provider documents a definitive diagnosis like “suspected prostate cancer” or “likely prostatitis,” you must code to that higher level of certainty.

Navigating the Clinical Pathway: From Code to Diagnosis

A single elevated PSA is often just the beginning of a clinical pathway. As a coder, your diagnosis codes will evolve alongside the patient’s journey.

1. Initial Finding: The patient has a routine PSA test showing an elevated level. The correct ICD-10 code for elevated prostate specific antigen is R97.20.

2. Further Investigation: The urologist performs a prostate biopsy.

3. Definitive Diagnosis:

   • If the biopsy is negative for cancer, the diagnosis might shift to N41.9 (Inflammatory disease of prostate, unspecified) or N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms), depending on the findings.

   • If the biopsy is positive for cancer, the primary diagnosis code permanently changes to C61 (Malignant neoplasm of prostate).

Understanding this pathway ensures your coding remains accurate and reflects the current stage of the patient’s care.

Frequently Asked Questions

What is the ICD-10 code for a rising PSA?
For a steadily increasing PSA level where no cancer has been diagnosed, the correct code is still R97.20 (Elevated prostate specific antigen [PSA]). The term “rising” describes the trend of the elevation, but the fundamental diagnosis for coding purposes remains an elevated PSA.

Can I use R97.20 for a screening PSA test?
No. For a routine screening PSA test on a patient with no symptoms and no prior elevated PSA, you should use a screening code. The appropriate code is Z12.5 (Encounter for screening for malignant neoplasm of prostate). You would only switch to R97.20 if the screening test result comes back elevated and that abnormal finding becomes the reason for further action.

What is the code for a family history of prostate cancer?
If a patient is being screened due to a family history, not because of their own symptoms or findings, you must use code Z80.42 (Family history of malignant neoplasm of prostate). This code takes precedence over a screening code when a family history is the motivating factor.

Why was my claim with R97.20 denied?
Denials for R97.20 typically occur for two reasons. First, the payer may require a more specific, confirmed diagnosis if the provider’s notes imply one (like “suspected prostatitis”). Second, some payers have specific policies about the medical necessity of repeat PSA testing, and you may need to provide additional clinical documentation to support the need for the service.

Is R97.20 billable for a diagnostic PSA test?
Yes, absolutely. R97.20 is a billable code. It is the standard and correct code to justify the medical necessity of a diagnostic PSA test—that is, a test performed to investigate a previously abnormal result or a specific symptom.