Epispadias
ICD-10 Q64.0 is a billable code used to indicate a diagnosis of epispadias.
Epispadias is a rare congenital malformation characterized by an abnormality in the development of the urethra, where the urethral opening is located on the dorsal (upper) surface of the penis in males or in the clitoral region in females. This condition can occur in isolation or as part of a more complex syndrome, such as bladder exstrophy. Epispadias can lead to urinary incontinence, recurrent urinary tract infections, and complications related to sexual function. The severity of the condition varies, and surgical intervention is often required to correct the anatomical defect and restore normal urinary function. The condition is associated with other congenital anomalies, particularly those affecting the urinary system, such as renal agenesis, bladder exstrophy, and posterior urethral valves. Accurate coding of epispadias requires careful documentation of associated conditions and the specific anatomical variations present in the patient.
Detailed pediatric history, physical examination findings, and surgical reports are essential for accurate coding.
Pediatric patients presenting with urinary incontinence, recurrent UTIs, or during routine examinations for congenital anomalies.
Consideration of the patient's age and developmental milestones when assessing the impact of epispadias.
Genetic counseling notes, family history of congenital anomalies, and any chromosomal studies performed.
Patients with epispadias presenting for genetic evaluation due to family history or associated syndromes.
Awareness of syndromic associations and the need for genetic testing in cases of complex presentations.
Used during surgical correction of epispadias in pediatric patients.
Surgical reports detailing the procedure and any complications.
Pediatric urology specialists should provide detailed operative notes.
The primary treatment for epispadias is surgical correction, which aims to reconstruct the urethra and restore normal urinary function. The timing and type of surgery depend on the severity of the condition and any associated anomalies.
