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v1.0.0
ICD-10 Guide
ICD-10 CodesQ53.21

Q53.21

Billable

Abdominal testis, bilateral

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

Code Description

ICD-10 Q53.21 is a billable code used to indicate a diagnosis of abdominal testis, bilateral.

Key Diagnostic Point:

Bilateral abdominal testis, also known as bilateral cryptorchidism, is a congenital condition where both testes fail to descend into the scrotum and remain located in the abdominal cavity. This condition is often diagnosed during routine pediatric examinations or when a child presents with issues related to undescended testes. The failure of the testes to descend can lead to various complications, including infertility, increased risk of testicular cancer, and potential psychological effects due to abnormal genital appearance. The condition is associated with other congenital malformations, such as hypospadias, where the urethral opening is not located at the tip of the penis, and ambiguous genitalia, where the external genitalia do not clearly indicate male or female. The management of bilateral abdominal testis typically involves surgical intervention, such as orchidopexy, to relocate the testes into the scrotum, ideally performed before the child reaches one year of age to minimize risks of complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and associated conditions
  • Need for precise documentation of testicular location and associated anomalies
  • Potential for multiple surgical interventions and follow-up codes
  • Differentiation from other forms of cryptorchidism

Audit Risk Factors

  • Inadequate documentation of the condition's severity
  • Failure to document associated congenital anomalies
  • Incorrect coding of surgical interventions
  • Misclassification of testicular location

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Pediatric documentation must include detailed physical examination findings, family history of congenital conditions, and any associated anomalies.

Common Clinical Scenarios

Common scenarios include routine examinations revealing undescended testes, referrals for surgical intervention, and follow-up visits post-orchidopexy.

Billing Considerations

Accurate coding requires careful attention to the timing of diagnosis and intervention, as well as any associated conditions.

Genetics

Documentation Requirements

Genetic documentation should include family history, genetic testing results, and any syndromic associations with the condition.

Common Clinical Scenarios

Genetic counseling may be needed for families with a history of congenital anomalies, and genetic testing may be indicated to rule out syndromic causes.

Billing Considerations

Consideration of chromosomal abnormalities that may be associated with cryptorchidism, such as Klinefelter syndrome, is essential.

Coding Guidelines

Inclusion Criteria

Use Q53.21 When
  • Official coding guidelines for congenital conditions emphasize the importance of accurate documentation of the condition, associated anomalies, and any surgical interventions performed
  • Coders should ensure that all relevant details are captured to support the diagnosis

Exclusion Criteria

Do NOT use Q53.21 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54640CPT Code

Orchidopexy

Clinical Scenario

Performed to correct bilateral abdominal testis in a child.

Documentation Requirements

Surgical report detailing the procedure and findings.

Specialty Considerations

Pediatric urologists should ensure accurate coding of the procedure based on the specific surgical technique used.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital conditions, including bilateral abdominal testis, which enhances the ability to track and manage these conditions effectively.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital conditions, including bilateral abdominal testis, which enhances the ability to track and manage these conditions effectively.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of congenital conditions, including bilateral abdominal testis, which enhances the ability to track and manage these conditions effectively.

Resources

Clinical References

  • •
    American Academy of Pediatrics - Cryptorchidism

Coding & Billing References

  • •
    American Academy of Pediatrics - Cryptorchidism

Frequently Asked Questions

What are the long-term implications of bilateral abdominal testis?

Long-term implications can include infertility, increased risk of testicular cancer, and potential psychological effects due to abnormal genital appearance. Early surgical intervention is recommended to mitigate these risks.