Undescended testicle, unspecified, bilateral
ICD-10 Q53.20 is a billable code used to indicate a diagnosis of undescended testicle, unspecified, bilateral.
Undescended testicle, or cryptorchidism, is a common congenital condition where one or both testicles fail to descend into the scrotum before birth. This condition can lead to complications such as infertility, testicular cancer, and hernias if not addressed. In bilateral cases, both testicles are undescended, which may be associated with other congenital anomalies, including hypospadias or ambiguous genitalia. The exact cause of cryptorchidism is often multifactorial, involving genetic, hormonal, and environmental factors. Diagnosis typically occurs during a physical examination in infancy or early childhood. Treatment options include hormonal therapy or surgical intervention (orchidopexy) to reposition the testicles into the scrotum. Early intervention is crucial to mitigate potential long-term complications. The condition is often documented alongside other congenital malformations of the genital organs, necessitating careful coding to ensure accurate representation of the patient's clinical status.
Detailed physical examination findings, including the presence of both testicles, associated anomalies, and any interventions performed.
Infants presenting with undescended testicles during routine check-ups, referrals for surgical evaluation, and follow-up visits post-orchidopexy.
Ensure accurate coding for any associated conditions such as hypospadias or ambiguous genitalia, which may require additional codes.
Genetic evaluation reports, family history of congenital conditions, and any chromosomal studies performed.
Cases where undescended testicles are part of a syndrome or genetic condition, requiring comprehensive genetic counseling.
Consider the implications of genetic syndromes that may present with cryptorchidism, such as Klinefelter syndrome or Turner syndrome.
Performed to correct undescended testicle in a pediatric patient.
Operative report detailing the procedure and findings.
Pediatric urology may require specific documentation standards.
Bilateral undescended testicles can have more serious implications for fertility and associated congenital anomalies. Accurate coding is essential for appropriate management and treatment planning.
