Prostate Cancer ICD-10-CM codes

Prostate cancer has a single code, C61, with no fourth character for laterality, grade, or stage. Gleason score, stage, and PSA level are documented but not captured in the code. Metastatic disease is coded separately: C79.51 for bone metastasis (the most common site), C77.5 for intrapelvic lymph nodes, and C79.82 for secondary neoplasm of genital organs when spread to adjacent structures is documented.

R97.20 (elevated PSA) is the code for an elevated screening result before a diagnosis is made; it is not assigned once C61 is confirmed. R97.21 (rising PSA following treatment for malignant neoplasm of prostate) is used for biochemical recurrence in a patient whose cancer was previously treated. If the provider documents recurrent prostate cancer rather than only a rising PSA, assign C61.

Hormone status codes Z19.1 (hormone sensitive malignancy status) and Z19.2 (hormone resistant, also called castration-resistant) are additional codes sequenced after C61. A patient on androgen deprivation therapy such as leuprolide is still under active treatment and keeps C61; add Z79.818 for long-term use of the agent. Active surveillance without treatment is also coded C61 because the cancer is present.

Z85.46 (personal history of malignant neoplasm of prostate) replaces C61 only when the cancer was excised or eradicated, there is no further treatment directed at it, and the provider documents no evidence of disease. Z15.03 reports a confirmed genetic susceptibility, such as a BRCA2 mutation. Z51.11 is principal when the encounter is solely for chemotherapy.