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ICD-10 Guide
ICD-10 CodesR86.4

R86.4

Abnormal immunological findings in specimens from male genital organs

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R86.4 is a billable code used to indicate a diagnosis of abnormal immunological findings in specimens from male genital organs.

Key Diagnostic Point:

R86.4 is used to classify abnormal immunological findings in specimens obtained from male genital organs, which may include abnormal results from tests such as semen analysis, biopsies, or other immunological assays. These findings can indicate various underlying conditions, including infections, autoimmune disorders, or malignancies. Symptoms may vary widely, including infertility, pain, or abnormal discharge. The abnormal findings may reflect issues such as elevated levels of specific antibodies, abnormal immune cell counts, or the presence of inflammatory markers. Accurate interpretation of these findings is crucial for diagnosis and treatment planning, as they can guide further investigations and management strategies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying conditions
  • Need for correlation with clinical findings
  • Interpretation of laboratory results can be complex
  • Documentation of symptoms and findings must be precise

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to link abnormal findings to specific symptoms
  • Misinterpretation of laboratory results
  • Inconsistent coding practices across providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including symptoms and previous medical conditions, must be documented to support the diagnosis.

Common Clinical Scenarios

Patients presenting with infertility or unexplained genital symptoms may undergo immunological testing.

Billing Considerations

Consideration of autoimmune disorders and their impact on male reproductive health is essential.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate symptoms and any relevant lab findings.

Common Clinical Scenarios

Patients may present with acute scrotal pain or swelling, necessitating rapid immunological assessment.

Billing Considerations

Emergency settings may require expedited testing and documentation to ensure timely diagnosis.

Coding Guidelines

Inclusion Criteria

Use R86.4 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the code is used only when abnormal immunological findings are documented and not classified elsewhere
  • Ensure that the findings are linked to clinical symptoms

Exclusion Criteria

Do NOT use R86.4 When
No specific exclusions found.

Related CPT Codes

86336CPT Code

Immunoassay for antibodies

Clinical Scenario

Used when testing for specific antibodies related to male infertility.

Documentation Requirements

Document the specific antibodies tested and the clinical rationale for testing.

Specialty Considerations

Urologists may frequently order these tests in the context of infertility evaluations.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abnormal immunological findings, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abnormal immunological findings, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What types of tests are associated with R86.4?

R86.4 is associated with various immunological tests, including semen analysis for anti-sperm antibodies, biopsies for immune cell profiling, and other assays that assess immune function in the male genital tract.