Undescended testicle, unilateral
ICD-10 Q53.1 is a billable code used to indicate a diagnosis of undescended testicle, unilateral.
Undescended testicle, or cryptorchidism, is a congenital condition where one or both testicles fail to descend into the scrotum before birth. In the case of unilateral undescended testicle, only one testicle is affected. This condition is often diagnosed during a physical examination shortly after birth. The undescended testicle may be located in the inguinal canal or may not be palpable at all. If left untreated, it can lead to complications such as infertility, testicular cancer, and hernias. The exact cause of cryptorchidism is not fully understood, but it is believed to involve a combination of genetic and environmental factors. The condition is more common in premature infants and those with low birth weight. Treatment typically involves surgical intervention, known as orchidopexy, to reposition the testicle into the scrotum, ideally performed before the child reaches 18 months of age to minimize risks of complications.
Detailed physical examination findings, including location of the undescended testicle and any associated anomalies.
A newborn presenting with an undescended testicle during a routine examination or a follow-up visit after initial diagnosis.
Consideration of the child's age and timing of surgical intervention is crucial for accurate coding.
Family history of congenital conditions, genetic counseling notes, and any chromosomal analysis results.
Assessment of a child with undescended testicle and family history of similar conditions or other congenital anomalies.
Genetic syndromes associated with cryptorchidism should be documented to support coding.
Surgical correction of undescended testicle in a pediatric patient.
Operative report detailing the procedure and findings.
Pediatric surgical documentation must include pre-operative and post-operative assessments.
Accurate coding of Q53.1 is crucial for proper treatment planning, reimbursement, and tracking of congenital conditions. It ensures that patients receive appropriate care and follow-up, and it helps in understanding the prevalence and outcomes of cryptorchidism.
