PSA (Prostatic Specific Antigen) Lab Value
This input is used for staging
Notes
**Note 1:** Physician statement of prostatic specific antigen (PSA) pre-diagnosis can be used to code this data item when no other information is available. **Note 2:** PSA is a prognostic factor required for AJCC staging. It affects the stage group in most cases. **Note 3:** Record to the nearest tenth in nanograms/milliliter (ng/ml) the last pre-diagnosis PSA lab value prior to diagnostic biopsy of prostate and treatment. The lab value may be recorded in the lab report, history and physical, or clinical statement in the pathology report, etc. * A lab value expressed in micrograms per liter (ug/L) is equivalent to the same value expressed in nanograms per milliliter (ng/ml) * Record 0.1 when the lab results are stated as less than 0.1 ng/ml with no exact value. * ***Examples:*** PSA of 7.2. Code 7.2 PSA of 10. Code 10.0 PSA of 8.56. Code 8.6 PSA of 110.35. Code 110.4 **Note 4:** A known lab value takes priority over codes XXX.2 and XXX.3 * The lab value takes priority even if the physician documents the interpretation * *Example:* Patient noted to have a PSA of 7.6. Physician notes that the value is elevated * Code 7.6 instead of XXX.3 (elevated) **Note 5:** A discrepancy between the PSA documented in the lab report and the PSA documented by the clinician may arise due to the clinician's adjusting the PSA value. Certain medications for benign prostatic hypertrophy (BPH) decrease the PSA. * If there is documentation by a clinician within the medical record of an adjusted PSA value, record the adjusted value. * The registrar does not adjust the PSA value based on BPH medication use. * If there is no documentation by a clinician within the medical record of an adjusted PSA value, record the PSA value provided. * The fact that an adjusted PSA value is being recorded should be documented in the Dx Proc - Lab Tests text field (NAACCR Item # 2550).| Code | Description |
|---|---|
| 0.1 | 0.1 or less nanograms/milliliter (ng/ml) (Exact value to nearest tenth of ng/ml) |
| 0.2-999.9 | 0.2 - 999.9 ng/ml (Exact value to nearest tenth of ng/ml) |
| XXX.1 | 1,000 ng/ml or greater |
| XXX.2 | Lab value not available, physician states PSA is negative/normal |
| XXX.3 | Lab value not available, physician states PSA is positive/elevated/high |
| XXX.7 | Test ordered, results not in chart |
| XXX.9 | Not documented in medical record PSA lab value not assessed or unknown if assessed |