The patient had no signs or symptoms of any prostate related illness prior to

The patient had no signs or symptoms of any prostate

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The patient had no signs or symptoms of any prostate-related illness prior to coming in for the screening. The screening code is appropriately used as the first-listed code to signify that this was for routine screening. The elevated PSA is reported as a secondary diagnosis to reflect that an abnormal lab value was found as a result of the screening procedure(s).
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Chapter 21. Factors Influencing Health Status and Contact with Health Services ICD-10-CM 2017 Chapter 21. Factors Influencing Health Status and Contact with Health Services Guidelines and Examples ICD-10-CM 2017 485 encounter (for example, a maternal or fetal condition may be suspected due to an abnormal test result). These codes should not be used when the condition is confirmed. In those cases, the confirmed condition should be coded. In addition, these codes are not for use if an illness or any signs or symptoms related to the suspected condition or problem are present. In such cases the diagnosis/symptom code is used. Additional codes may be used in addition to the code from subcategory Z03.7, but only if they are unrelated to the suspected condition being evaluated. Codes from subcategory Z03.7 may not be used for encounters for antenatal screening of mother. See Section I.C.21. Screening . For encounters for suspected fetal condition that are inconclusive following testing and evaluation, assign the appropriate code from category O35, O36, O40 or O41. The observation Z code categories: Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z04 Encounter for examination and observation for other reasons Except: Z04.9, Encounter for examination and observation for unspecified reason Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out 7) Aftercare Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. Exceptions to this rule are codes Z51.0, Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy. These codes are to be first-listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm. If the reason for the encounter is more than one type of antineoplastic therapy, code Z51.0 and a code from subcategory Z51.1 may be assigned together, in which case one of these codes would be reported as a secondary diagnosis.
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