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ICD-10 Guide
ICD-10 CodesN48.21

N48.21

Billable

Abscess of corpus cavernosum and penis

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

Code Description

ICD-10 N48.21 is a billable code used to indicate a diagnosis of abscess of corpus cavernosum and penis.

Key Diagnostic Point:

An abscess of the corpus cavernosum and penis is a localized collection of pus within the erectile tissue of the penis, often resulting from infection. This condition can arise due to various factors, including trauma, sexually transmitted infections, or other infectious processes. Clinically, patients may present with symptoms such as penile pain, swelling, erythema, and fever. The abscess can lead to complications such as erectile dysfunction, penile necrosis, or systemic infection if not treated promptly. Diagnosis typically involves a thorough physical examination, imaging studies like ultrasound, and laboratory tests to identify the causative organism. Treatment usually includes antibiotics and may require surgical intervention for drainage of the abscess. Understanding the underlying causes and associated conditions, such as hydrocele, orchitis, and other testicular disorders, is crucial for comprehensive management and to prevent recurrence.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between abscess and other penile disorders
  • Understanding associated conditions like orchitis and hydrocele
  • Need for precise documentation of symptoms and treatment
  • Potential for multiple underlying causes requiring thorough investigation

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify the type of abscess
  • Lack of follow-up documentation post-treatment
  • Misclassification of abscess severity

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed clinical notes on symptoms, imaging results, and treatment plans.

Common Clinical Scenarios

Management of penile abscesses, evaluation of erectile dysfunction, and treatment of sexually transmitted infections.

Billing Considerations

Ensure accurate documentation of the abscess location and any associated conditions.

Infectious Disease

Documentation Requirements

Comprehensive history of infection, laboratory results, and treatment response.

Common Clinical Scenarios

Diagnosis and management of infections leading to abscess formation.

Billing Considerations

Document the infectious etiology and any systemic involvement.

Coding Guidelines

Inclusion Criteria

Use N48.21 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the abscess type and associated conditions
  • Include any relevant clinical findings and treatment details

Exclusion Criteria

Do NOT use N48.21 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54050CPT Code

Incision and drainage of abscess, penis

Clinical Scenario

Used when surgical intervention is required for abscess drainage.

Documentation Requirements

Document the size, location, and nature of the abscess, along with the procedure details.

Specialty Considerations

Urologists should ensure that all relevant clinical findings are 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 abscess of the corpus cavernosum, improving data accuracy and facilitating better patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like abscess of the corpus cavernosum, improving data accuracy and facilitating better patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like abscess of the corpus cavernosum, improving data accuracy and facilitating better patient management.

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 causes of an abscess in the corpus cavernosum?

Common causes include bacterial infections, trauma, and complications from sexually transmitted infections. Proper diagnosis and management are essential to prevent complications.