ICD-10 Coding for History of Prostate Cancer(Z85.46)
Complete ICD-10-CM coding and documentation guide for History of Prostate Cancer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Prostate Cancer
Z85.46Primary Range
Personal history of malignant neoplasm of prostate
Used to indicate a history of prostate cancer when the patient is no longer receiving active treatment and there is no evidence of disease.
Encounter for follow-up examination after completed treatment for malignant neoplasm
Used for follow-up visits after treatment for prostate cancer to monitor for recurrence.
Key Information: ICD-10 code for history of prostate cancer
Essential facts and insights about History of Prostate Cancer
Primary ICD-10-CM Code for history of prostate cancer
Decision Criteria
clinical Criteria
- Patient has completed treatment and shows no evidence of disease.
documentation Criteria
- Documentation must indicate 'history of prostate cancer' and include treatment details.
Applicable To
- History of prostate cancer
- Prostate cancer in remission
Excludes
- Active prostate cancer (C61)
Clinical Validation Requirements
- Undetectable PSA levels
- No evidence of disease on imaging
- Completed treatment with no recurrence
Code-Specific Risks
- Incorrectly coding as active cancer when treatment is complete
- Not documenting the absence of disease
Coding Notes
- Ensure documentation clearly states the history and current status of the cancer.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for follow-up examination after completed treatment for malignant neoplasm
Z08Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Prostate Cancer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z85.46.
Impact
Clinical: Misrepresentation of patient's current health status., Regulatory: Potential for audit and non-compliance issues., Financial: Incorrect billing and reimbursement.
Mitigation Strategy
Verify treatment status before coding, Ensure documentation supports remission status
Impact
Reimbursement: Incorrect coding can lead to overpayment and potential audits., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use Z85.46 for history of prostate cancer when there is no active treatment or evidence of disease.
Impact
Using active cancer codes for patients in remission.
Mitigation Strategy
Regular training on coding guidelines and documentation review.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Prostate Cancer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Prostate Cancer
Use these documentation templates to ensure complete and accurate documentation for History of Prostate Cancer. These templates include all required elements for proper coding and billing.
Post-treatment follow-up
Specialty: UrologyRequired Elements
- Patient history
- Treatment details
- Current status
- PSA levels
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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