Hypospadias, penile
ICD-10 Q54.1 is a billable code used to indicate a diagnosis of hypospadias, penile.
Hypospadias is a congenital malformation of the male urethra characterized by the abnormal placement of the urethral opening on the ventral surface of the penis, rather than at the tip of the glans. This condition can vary in severity, with the urethral opening potentially located anywhere along the shaft of the penis, or even at the base of the penis or in the scrotum. Hypospadias is often associated with other genital anomalies, such as chordee (curvature of the penis) and cryptorchidism (undescended testicles). The exact etiology of hypospadias is not fully understood, but it is believed to involve a combination of genetic and environmental factors. Diagnosis is typically made at birth during a physical examination. Surgical correction is usually recommended to improve urinary function and cosmetic appearance, with the timing of surgery often occurring between 6 months and 18 months of age. Hypospadias can be classified into three types: glandular, penile, and perineal, based on the location of the urethral opening. Accurate coding is essential for proper management and treatment planning.
Detailed physical examination findings, including the location of the urethral opening and any associated anomalies.
Newborns presenting with hypospadias during routine examinations, cases requiring surgical intervention, and follow-up visits post-surgery.
Ensure that all associated conditions are documented to avoid undercoding or misclassification.
Family history of congenital anomalies, genetic testing results if applicable, and any syndromic associations.
Cases where hypospadias is part of a genetic syndrome, such as Turner syndrome or Klinefelter syndrome.
Consider the implications of genetic counseling for families with a history of congenital malformations.
Used during surgical correction of hypospadias.
Operative report detailing the procedure performed and any complications.
Pediatric urology specialists typically perform this procedure.
Accurate coding of hypospadias is crucial for proper treatment planning, reimbursement, and tracking of congenital anomalies. It ensures that patients receive appropriate care and that healthcare providers are compensated for their services.
