Question

A 67 year old patient diagnosed with prostate cancer that is castrate resistant is admitted for malignancy related pain. Despite treatment withthe androgen deprivation therapy (ADT) drug leuprorelin, the patient has a rise in serum levels of prostate-specific antigen (PSA).

How is this case coded and sequenced?

A. C61, R97.21, Z79.818
B. G89.3, C79.82, R97.21, Z19.2
C. C63.9, G89.3, Z19.2, Z79.818
D. G89.3 ,C61, R97.21, Z19.2, Z79.818

Answer 1

The appropriate coding and sequencing for a 67-year-old patient with castrate-resistant prostate cancer and rising PSA levels despite ADT is D (G89.3, C61, R97.21, Z19.2, Z79.818), which captures the pain, primary cancer diagnosis, PSA status, hormone sensitivity, and ADT use.

Step-by-step explanation:

The correct coding and sequencing for a 67-year-old patient diagnosed with castrate-resistant prostate cancer, who is experiencing malignancy related pain and has a rising serum level of prostate-specific antigen (PSA) despite treatment with the androgen deprivation therapy (ADT) drug leuprorelin, would be D. G89.3 (Pain, not elsewhere classified), C61 (Malignant neoplasm of prostate), R97.21 (Rising PSA following treatment for malignant neoplasm of prostate), Z19.2 (Hormone sensitivity malignancy status), and Z79.818 (Long term (current) use of other agents affecting estrogen receptors and estrogen levels).

This sequence includes codes for the patient’s pain, primary cancer diagnosis, rising PSA levels, cancer's hormone sensitivity, and the use of hormone therapy. The patient's primary diagnosis, which is the castrate-resistant prostate cancer, is represented by C61 and would typically be sequenced first followed by the associated secondary conditions and treatment statuses.