June is Men’s Health Month, when we focus on prevention, detection and treatment of disease in men and boys. As a cardiologist, it is tempting for me to use this platform to talk about heart disease. Instead I have decided to push myself beyond that, connecting to my cardiology roots while shooting for some extra bonus points by mentioning coding and Clinical Documentation Improvement.

I saw a patient in the office for follow-up two weeks after an acute inferior MI caused by a right coronary artery occlusion (that would be ICD-10 code I2.11). Keep in mind that the meaning of “initial” and “subsequent” for MIs has changed since ICD-9, where it referred to the episode of care. But under ICD-10, this office visit for the single MI within the previous 4 weeks did not get any special code modifier.

As he was leaving, the patient asked me to check his PSA (the Prostate-Specific Antigen which is used to help detect and screen for prostate cancer). Apparently his family doctor normally did this, but it hadn’t been checked in a while. He called a few weeks later to tell me that his insurance company refused to pay for the PSA check, as the test is not indicated in the context of a follow up visit after a heart attack. It would have been covered if I had documented our discussion and coded for an encounter for screening for prostate cancer (Z12.5). [See how I snuck in a mention of coding and Clinical Documentation Improvement?]

Well, not too long after that, my friend Joe called, upset that his PSA test was high, and had increased since the previous test. This change is sometimes referred as the velocity of the PSA blood level. Fortunately, I enjoy acting as a “medical concierge,” as I know many good doctors, many nice doctors, and a few who are both. I referred Joe to a nice and good urologist, knowing that he was headed for a prostate biopsy.

Joe called a few weeks later while I was eating dinner, anxious to share the news that the biopsy was done in the urologist’s office, was totally painless and that the pathology results completely benign. He went on to describe the biopsy procedure in a little greater detail than I needed to hear while eating dinner. A total of twelve prostate samples were taken – one at a time – using a spring-loaded needle device that was inserted through the rectum, along with an ultrasound probe to guide the biopsy location.

He said that the biopsy device sounded just like a staple gun, and he was not sure that he would ever be able to use a staple gun again. This is most unfortunate, since Joe does construction work. He also described his experience trying to tell his wife about the procedure, and how undignified the whole thing was.

She apparently replied “Yeah, tell me about it,” no doubt thinking about her annual pelvic exam and Pap smear. [We’ll have to save further discussion of that for next January, which is Cervical Health Awareness Month.]

Prostate cancer is the most common cancer in men in the United States, and the second most common cause of men’s cancer deaths. It may not cause any symptoms, and unfortunately half the time it has already spread by the time the diagnosis is made. Early detection is important, with the goal of detecting it when it is still localized and is potentially curable.

Despite these facts, you don’t hear much about prostate cancer in the media until, of course, a celebrity is diagnosed with the disease. You should spend a few minutes doing an internet search using the search terms “prostate cancer” and “celebrity.” You’ll be amazed at the list, which includes:

  • ACTORS: Charlton Heston, Laurence Olivier, Robert DeNiro and Roger Moore
  • POLITICAL FIGURES: Robert Dole, John Kerry, Rudy Giuliani and Colin Powell
  • ATHLETES: Stan Musial, Arnold Palmer, Ty Cobb and Joe Torre
  • MUSICIANS: Frank Zappa, Harry Belafonte, James Brown, and two of my personal favorites Dan Fogelberg and gentle soul Jesse Winchester

The American Cancer Society recommends prostate screening for all men over age 50. Men at higher risk – for example, African-Americans, and those with a family history of prostate cancer – should be screened starting at age 45. Screening is typically done during a rectal exam, checking the feel of the prostate with a gloved finger. This may be augmented by checking a PSA blood test. Medicare and most insurance companies will reimburse for the testing to be done annually.

To summarize best practices for prostate cancer screening:

  • Men who fall into one of the two categories above: make sure you get your annual screening, this year and every year.
  • Providers: be sure to do annual screening for the prostate health status of your eligible patients. Discuss this with your patient and document the need for the screening, and the date and results of the last screening if any.
  • Coders: be sure that the medical necessity is documented and properly coded. By the way, if a Digital Rectal Exam is performed as part of other Evaluation and Management services done on the same day, this gets bundled in rather than being coded separately.
  • And, ladies: cut your man some slack. Give him a one-time pass to whine about the undignified and embarrassing examination of his private parts. Let him think that his is the only gender that has to suffer this indignity. You can always enlighten him tomorrow.

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