Bilateral non-palpable testicles
ICD-10 R39.84 is a billable code used to indicate a diagnosis of bilateral non-palpable testicles.
Bilateral non-palpable testicles refer to a clinical finding where both testicles are not detectable upon physical examination. This condition can arise from various etiologies, including congenital anomalies such as cryptorchidism, hormonal imbalances, or anatomical abnormalities. In infants, the absence of palpable testicles may indicate undescended testicles, which can lead to complications such as infertility or malignancy if not addressed. In adults, non-palpable testicles may be associated with conditions like testicular agenesis or previous surgical interventions. Diagnosis typically involves a thorough physical examination, imaging studies such as ultrasound, and hormonal evaluations to assess the underlying causes. Accurate documentation of the clinical findings and any associated symptoms is crucial for proper coding and management.
Detailed history of the patient's reproductive health, physical examination findings, and any relevant imaging or lab results.
Evaluation of a patient presenting with infertility or hormonal imbalances.
Consideration of endocrine evaluations to rule out hormonal causes.
Acute care notes including physical examination findings and any immediate interventions.
Acute presentation of scrotal pain or trauma where testicular status is assessed.
Rapid assessment and documentation are critical in emergency settings.
When surgical intervention is required for undescended testicles.
Surgical notes detailing the procedure and findings.
Urology specialists will need to document the rationale for surgery.
Common causes include cryptorchidism, testicular agenesis, hormonal imbalances, and previous surgical interventions.
Document the physical examination findings, any imaging studies performed, and the clinical context leading to the diagnosis.
