Hypospadias, balanic
ICD-10 Q54.0 is a billable code used to indicate a diagnosis of hypospadias, balanic.
Hypospadias is a congenital malformation characterized by the abnormal positioning of the urethral opening on the ventral surface of the penis. In balanic hypospadias, the urethral meatus is located at the glans penis, which is the most distal form of this condition. This anomaly can lead to various complications, including difficulties with urination, potential for urinary tract infections, and challenges with sexual function later in life. The condition is often diagnosed at birth during a physical examination. Treatment typically involves surgical intervention to reposition the urethral opening to its normal location, which is usually performed between 6 to 18 months of age. The etiology of hypospadias is multifactorial, involving genetic, hormonal, and environmental factors. It is important for healthcare providers to document the specific type and severity of hypospadias, as well as any associated anomalies, to ensure appropriate coding and management.
Detailed physical examination findings, surgical notes, and follow-up care documentation.
Newborns presenting with hypospadias, surgical repair in early childhood, and management of complications.
Consideration of parental concerns and education regarding the condition and its management.
Family history, genetic counseling notes, and any genetic testing results.
Assessment of hypospadias in the context of syndromic presentations or familial patterns.
Understanding the genetic basis and potential chromosomal abnormalities associated with hypospadias.
Used during surgical correction of hypospadias.
Operative report detailing the procedure and findings.
Pediatric urologists should ensure accurate coding of the procedure based on the type of hypospadias.
Coding the specific type of hypospadias is crucial for accurate treatment planning, understanding potential complications, and ensuring appropriate reimbursement for surgical interventions.
