Congenital absence and aplasia of penis
ICD-10 Q55.5 is a billable code used to indicate a diagnosis of congenital absence and aplasia of penis.
Congenital absence and aplasia of the penis, classified under Q55.5, refers to a condition where the penis is either partially or completely absent at birth. This condition can occur as an isolated anomaly or as part of a syndrome involving other congenital malformations. The absence of the penis can be associated with other genital anomalies such as hypospadias, cryptorchidism, or ambiguous genitalia. In some cases, it may be linked to chromosomal abnormalities, such as Turner syndrome or Klinefelter syndrome, which can affect sexual development. Diagnosis typically involves physical examination and may require imaging studies to assess the presence of other genital structures. Management may include surgical intervention, hormonal therapy, and psychological support, particularly as the child approaches puberty. Accurate coding is essential for appropriate treatment planning and insurance reimbursement, as well as for tracking the incidence of such congenital conditions in the pediatric population.
Pediatric documentation must include detailed physical examination findings, family history, and any associated congenital anomalies. Growth and development assessments are also crucial.
Common scenarios include newborns presenting with absent or malformed genitalia, cases of hypospadias, and referrals for surgical correction.
Coders should be aware of the psychosocial implications of genital anomalies and ensure that documentation reflects the comprehensive care provided.
Genetic documentation should include family history of congenital anomalies, results of genetic testing, and any syndromic associations.
Scenarios may involve genetic counseling for families with a history of congenital genital anomalies or syndromes associated with genital malformations.
Consideration of chromosomal abnormalities is essential, as conditions like Turner syndrome may present with genital anomalies.
Used in cases of congenital absence or severe hypospadias.
Detailed operative report and pre-operative assessment.
Pediatric urologists should document the rationale for surgical intervention.
Q55.5 refers specifically to congenital absence and aplasia of the penis, while Q55.0 is used for cases of complete absence without aplasia. Accurate documentation is crucial to differentiate between these conditions.
