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v1.0.0
ICD-10 Guide
ICD-10 CodesN48.1

N48.1

Billable

Balanitis

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

Code Description

ICD-10 N48.1 is a billable code used to indicate a diagnosis of balanitis.

Key Diagnostic Point:

Balanitis is an inflammation of the glans penis, which can be caused by a variety of factors including infections (bacterial, viral, or fungal), irritants (such as soaps or chemicals), or underlying medical conditions (like diabetes). Symptoms typically include redness, swelling, itching, and pain in the affected area. In some cases, balanitis can lead to phimosis, where the foreskin cannot be retracted, complicating the condition further. It is essential to differentiate between balanitis and other penile disorders, such as balanoposthitis, which involves inflammation of both the glans and the foreskin. Treatment often involves topical antifungal or antibacterial medications, improved hygiene practices, and in chronic cases, circumcision may be considered. Balanitis can also be associated with other male reproductive health issues, such as orchitis, hydrocele, and male infertility, necessitating a comprehensive approach to andrological management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes
  • Differentiation from similar conditions (e.g., balanoposthitis)
  • Need for detailed patient history and examination findings
  • Potential for co-existing conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of symptoms and treatment
  • Failure to specify the underlying cause of balanitis
  • Misclassification with other penile disorders
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed patient history, physical examination findings, and treatment plans must be documented.

Common Clinical Scenarios

Patients presenting with symptoms of penile inflammation, recurrent infections, or complications from diabetes.

Billing Considerations

Consideration of underlying conditions such as diabetes or sexually transmitted infections that may complicate treatment.

Dermatology

Documentation Requirements

Photographic evidence of lesions, detailed descriptions of skin findings, and response to treatments.

Common Clinical Scenarios

Patients with dermatological manifestations on the genitalia, including balanitis due to contact dermatitis.

Billing Considerations

Differentiating between infectious and non-infectious causes of balanitis.

Coding Guidelines

Inclusion Criteria

Use N48.1 When
  • According to ICD
  • 10 guidelines, N48
  • 1 should be used when the primary diagnosis is balanitis
  • It is important to document the specific cause of the balanitis if known, as this may affect treatment and management

Exclusion Criteria

Do NOT use N48.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54160CPT Code

Circumcision, surgical excision of foreskin

Clinical Scenario

Used in cases of recurrent balanitis or phimosis.

Documentation Requirements

Document the indication for circumcision and any prior treatments attempted.

Specialty Considerations

Urologists should ensure that all conservative measures have been exhausted before proceeding with surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of balanitis, improving the ability to capture the nuances of the condition and its management. This specificity aids in better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of balanitis, improving the ability to capture the nuances of the condition and its management. This specificity aids in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    American Urological Association Guidelines

Coding & Billing References

  • •
    American Urological Association Guidelines

Frequently Asked Questions

What are the common causes of balanitis?

Common causes of balanitis include infections (such as yeast infections or sexually transmitted infections), irritants (like soaps or lotions), and underlying conditions such as diabetes or skin disorders.