Hypospadias, perineal
ICD-10 Q54.3 is a billable code used to indicate a diagnosis of hypospadias, perineal.
Hypospadias is a congenital malformation of the male urethra characterized by the abnormal placement of the urethral opening. In perineal hypospadias, the urethral opening is located in the perineum, which is the area between the scrotum and the anus. This condition can lead to various complications, including difficulties with urination, potential for urinary tract infections, and challenges with sexual function later in life. The severity of hypospadias can vary, and it is often associated with other congenital anomalies, such as cryptorchidism (undescended testicles) and ambiguous genitalia. Diagnosis is typically made at birth through physical examination, and management often involves surgical intervention to correct the urethral opening's position. The timing of surgery is crucial, with many practitioners recommending repair between 6 to 18 months of age to optimize outcomes. Hypospadias can also be part of broader syndromic presentations, necessitating a thorough evaluation for associated anomalies.
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.
Consideration of the psychological impact on the child and family, as well as the timing of surgical intervention.
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.
Assessment for chromosomal abnormalities and genetic counseling for families.
Used during surgical correction of perineal hypospadias.
Operative report detailing the procedure performed and any associated findings.
Pediatric urology specialists typically perform this procedure.
Accurate coding of perineal hypospadias is crucial for appropriate management, surgical planning, and tracking of outcomes. It also ensures proper reimbursement and supports research into congenital conditions.
