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v1.0.0
ICD-10 Guide
ICD-10 CodesN48.0

N48.0

Billable

Leukoplakia of penis

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N48.0 is a billable code used to indicate a diagnosis of leukoplakia of penis.

Key Diagnostic Point:

Leukoplakia of the penis is characterized by the presence of white patches or plaques on the penile mucosa, which may be indicative of underlying conditions such as irritation, infection, or precancerous changes. This condition is often associated with chronic irritation, which can stem from various factors including poor hygiene, sexually transmitted infections (STIs), or irritants such as soaps and lotions. Clinically, leukoplakia may present as asymptomatic or may be accompanied by discomfort, itching, or pain. Diagnosis typically involves a thorough clinical examination and may require biopsy to rule out malignancy, particularly in cases where lesions are persistent or atypical. Management strategies may include addressing the underlying cause, such as treating infections or advising on hygiene practices. In some cases, surgical intervention may be necessary if there is a concern for dysplasia or malignancy. Regular follow-up is essential to monitor for changes in the lesions and to ensure appropriate management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Potential overlap with other penile disorders such as lichen sclerosus or penile cancer.
  • Need for thorough documentation to differentiate from similar conditions.
  • Variability in presentation and symptoms that may complicate diagnosis.
  • Requirement for biopsy or further investigation to confirm diagnosis.

Audit Risk Factors

  • Inadequate documentation of clinical findings.
  • Failure to document the rationale for biopsy or treatment.
  • Misclassification of leukoplakia as a benign condition without further investigation.
  • Lack of follow-up documentation to monitor changes in the condition.

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed clinical notes including patient history, physical examination findings, and any diagnostic tests performed.

Common Clinical Scenarios

Patients presenting with penile lesions, chronic irritation, or unexplained penile discomfort.

Billing Considerations

Urologists should ensure that any biopsies or treatments are well-documented to support coding and billing.

Dermatology

Documentation Requirements

Comprehensive skin examination notes, including descriptions of lesions and any treatments applied.

Common Clinical Scenarios

Patients with skin lesions on the genital area, particularly those with a history of STIs or chronic skin conditions.

Billing Considerations

Dermatologists should document the appearance of lesions and any differential diagnoses considered.

Coding Guidelines

Inclusion Criteria

Use N48.0 When
  • According to ICD
  • 10 coding guidelines, N48
  • 0 should be used when leukoplakia is specifically identified on the penis
  • Coders must ensure that the diagnosis is supported by clinical documentation and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use N48.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

11100CPT Code

Biopsy of skin, subcutaneous tissue, and/or mucous membrane

Clinical Scenario

Used when a biopsy is performed to evaluate leukoplakia.

Documentation Requirements

Document the reason for biopsy, findings, and any follow-up plans.

Specialty Considerations

Urologists and dermatologists should ensure that the biopsy site and findings are clearly documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like leukoplakia, improving the accuracy of diagnoses and treatment tracking. This specificity aids in better patient management and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like leukoplakia, improving the accuracy of diagnoses and treatment tracking. This specificity aids in better patient management and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like leukoplakia, improving the accuracy of diagnoses and treatment tracking. This specificity aids in better patient management and resource allocation.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common symptoms of leukoplakia of the penis?

Common symptoms include white patches on the penis, potential itching, discomfort, or pain, especially if there is associated inflammation or irritation.

How is leukoplakia of the penis diagnosed?

Diagnosis is typically made through clinical examination, and may require biopsy to confirm the diagnosis and rule out malignancy.

What treatment options are available for leukoplakia of the penis?

Treatment may involve addressing underlying causes, such as infections or irritants, and in some cases, surgical intervention may be necessary if there is concern for dysplasia or malignancy.