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v1.0.0
ICD-10 Guide
ICD-10 CodesQ53.212

Q53.212

Billable

Bilateral inguinal testes

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

Code Description

ICD-10 Q53.212 is a billable code used to indicate a diagnosis of bilateral inguinal testes.

Key Diagnostic Point:

Bilateral inguinal testes, also known as bilateral inguinal cryptorchidism, is a congenital condition where both testes fail to descend into the scrotum and are located in the inguinal canal. This condition is often diagnosed during a physical examination in infancy or early childhood. The testes may be palpable in the inguinal canal, but they are not in their normal anatomical position. The failure of descent can be attributed to various factors, including hormonal imbalances, anatomical abnormalities, or genetic predispositions. If left untreated, bilateral inguinal testes can lead to complications such as infertility, testicular torsion, and an increased risk of testicular cancer. Surgical intervention, typically via orchidopexy, is the standard treatment to reposition the testes into the scrotum. Early diagnosis and management are crucial for optimal outcomes, and pediatricians often collaborate with urologists for comprehensive care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and diagnosis timing
  • Need for precise anatomical localization
  • Potential for associated conditions (e.g., hypospadias, ambiguous genitalia)
  • Documentation of surgical interventions and follow-up care

Audit Risk Factors

  • Inadequate documentation of testicular location
  • Failure to document associated congenital anomalies
  • Incorrect coding of surgical procedures performed
  • Misinterpretation of the condition as acquired rather than congenital

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed physical examination findings, including testicular location and size, and any associated anomalies.

Common Clinical Scenarios

Infants presenting with undescended testes during routine check-ups, referrals for surgical intervention.

Billing Considerations

Consideration of the child's age and developmental milestones when planning surgical intervention.

Genetics

Documentation Requirements

Family history of cryptorchidism or other congenital anomalies, genetic testing results if applicable.

Common Clinical Scenarios

Genetic counseling for families with a history of congenital malformations, evaluation for syndromic associations.

Billing Considerations

Awareness of chromosomal abnormalities that may present with cryptorchidism, such as Klinefelter syndrome.

Coding Guidelines

Inclusion Criteria

Use Q53.212 When
  • Follow the official ICD
  • CM coding guidelines for congenital conditions, ensuring accurate documentation of the condition's nature, associated anomalies, and any surgical interventions performed

Exclusion Criteria

Do NOT use Q53.212 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54640CPT Code

Orchidopexy

Clinical Scenario

Performed to correct bilateral inguinal testes.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Pediatric urologists should ensure accurate coding of the procedure in relation to the diagnosis.

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, improving the accuracy of data collection and reimbursement processes. The granularity of ICD-10 codes enables better tracking of congenital anomalies and their management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital conditions, improving the accuracy of data collection and reimbursement processes. The granularity of ICD-10 codes enables better tracking of congenital anomalies and their management.

Reimbursement & Billing Impact

reimbursement processes. The granularity of ICD-10 codes enables better tracking of congenital anomalies and their management.

Resources

Clinical References

  • •
    American Academy of Pediatrics - Cryptorchidism

Coding & Billing References

  • •
    American Academy of Pediatrics - Cryptorchidism

Frequently Asked Questions

What is the significance of coding bilateral inguinal testes accurately?

Accurate coding of bilateral inguinal testes is crucial for appropriate treatment planning, monitoring for associated conditions, and ensuring proper reimbursement for surgical interventions. It also aids in the collection of data for research and public health initiatives related to congenital anomalies.