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ICD-10 Guide
ICD-10 CodesN48.81

N48.81

Billable

Thrombosis of superficial vein of penis

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

Code Description

ICD-10 N48.81 is a billable code used to indicate a diagnosis of thrombosis of superficial vein of penis.

Key Diagnostic Point:

Thrombosis of the superficial vein of the penis is a condition characterized by the formation of a thrombus (blood clot) within the superficial venous system of the penis. This condition can lead to localized swelling, pain, and discoloration of the penile tissue. It may occur due to various factors, including trauma, prolonged sexual activity, or underlying vascular disorders. Patients may present with symptoms such as a palpable cord-like structure along the vein, tenderness, and sometimes erectile dysfunction. Diagnosis is typically made through clinical examination and may be supported by imaging studies such as Doppler ultrasound to assess blood flow and confirm the presence of a thrombus. Management often involves conservative measures, including analgesics, ice application, and in some cases, anticoagulation therapy. In severe cases, surgical intervention may be necessary to remove the clot or address underlying venous insufficiency. Understanding this condition is crucial for andrological management, as it can impact male fertility and sexual health.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of presenting symptoms that may overlap with other conditions
  • Need for accurate clinical documentation to support diagnosis
  • Potential for misdiagnosis with other penile disorders
  • Variability in treatment approaches based on severity

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings
  • Failure to document imaging studies performed
  • Misclassification of the condition as a more severe disorder
  • Lack of follow-up documentation for treatment outcomes

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed clinical notes including patient history, physical examination findings, and treatment plans.

Common Clinical Scenarios

Patients presenting with penile pain, swelling, or erectile dysfunction.

Billing Considerations

Ensure documentation reflects the acute nature of the condition and any interventions performed.

Andrology

Documentation Requirements

Comprehensive assessment of male reproductive health, including fertility evaluations.

Common Clinical Scenarios

Men with infertility issues presenting with vascular complications.

Billing Considerations

Document any impact on fertility and sexual function, as this may influence treatment decisions.

Coding Guidelines

Inclusion Criteria

Use N48.81 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the condition's severity and any associated symptoms
  • Include relevant imaging studies and treatment plans in the documentation

Exclusion Criteria

Do NOT use N48.81 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

36415CPT Code

Venous blood draw

Clinical Scenario

Used when blood tests are required to assess underlying conditions.

Documentation Requirements

Document the reason for the blood draw and any relevant clinical findings.

Specialty Considerations

Urologists may need to document specific tests related to male reproductive health.

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 thrombosis of the superficial vein of the penis, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like thrombosis of the superficial vein of the penis, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 thrombosis of the superficial vein of the penis?

Common symptoms include localized swelling, pain, tenderness, and discoloration of the penile tissue. Patients may also experience erectile dysfunction.