Document status to support accurate coding

Accurate documentation of prostate cancer status helps support appropriate coding, reflect patient complexity, and align care resources with patient needs. Providers should clearly indicate whether prostate cancer is active, under treatment, recurrent, metastatic, or historical with no evidence of disease.

Provider takeaway

Prostate cancer documentation should clearly state whether the condition is active/current or historical. Start with disease status, then support it with treatment intent and PSA context. Indicate active prostate cancer for current disease, recurrence, metastasis, or active treatment. Indicate history of prostate cancer when treatment is complete with no evidence of disease.

Use the guidance below to help document prostate cancer status consistently and support accurate coding.

TIP: The assessment and plan should tell the same story: current disease status, treatment intent, and follow-up plan.