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ICD-10 Guide
ICD-10 CodesQ53.9

Q53.9

Billable

Undescended testicle, unspecified

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

Code Description

ICD-10 Q53.9 is a billable code used to indicate a diagnosis of undescended testicle, unspecified.

Key Diagnostic Point:

Undescended testicle, or cryptorchidism, is a congenital condition where one or both testicles fail to descend into the scrotum before birth. This condition is commonly diagnosed in newborns and can lead to complications such as infertility, testicular cancer, and hernias if left untreated. The exact cause of undescended testicles is often multifactorial, involving genetic, hormonal, and environmental factors. In some cases, the testicle may descend spontaneously within the first few months of life. However, if it does not, surgical intervention, typically orchidopexy, is recommended to position the testicle in the scrotum. The condition can occur in isolation or be associated with other congenital malformations of the genital organs, such as hypospadias or ambiguous genitalia. Accurate diagnosis and timely intervention are crucial for optimal outcomes in affected individuals.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and associated conditions
  • Need for precise documentation of the condition's laterality
  • Potential for co-occurring congenital anomalies
  • Variations in treatment protocols and follow-up care

Audit Risk Factors

  • Inadequate documentation of the condition's specifics
  • Failure to note associated congenital anomalies
  • Incorrect coding of laterality
  • Lack of follow-up documentation post-surgery

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Pediatric documentation should include birth history, physical examination findings, and any associated anomalies. Detailed notes on the timing of diagnosis and treatment plans are essential.

Common Clinical Scenarios

Common scenarios include routine newborn examinations revealing undescended testicles, referrals for surgical evaluation, and follow-up visits post-orchidopexy.

Billing Considerations

Considerations include the age of the child at diagnosis, potential for spontaneous descent, and the presence of other congenital anomalies.

Genetics

Documentation Requirements

Genetic documentation should include family history of congenital conditions, genetic testing results if applicable, and any syndromic associations.

Common Clinical Scenarios

Scenarios may involve genetic counseling for families with a history of cryptorchidism or associated syndromes, and discussions about the implications of genetic findings.

Billing Considerations

Considerations include the potential for chromosomal abnormalities that may present with undescended testicles, such as Klinefelter syndrome.

Coding Guidelines

Inclusion Criteria

Use Q53.9 When
  • According to ICD
  • 10 coding guidelines, congenital conditions should be coded based on the specific diagnosis and any associated anomalies
  • Documentation must support the diagnosis and any interventions performed

Exclusion Criteria

Do NOT use Q53.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54640CPT Code

Orchidopexy

Clinical Scenario

Used for surgical correction of undescended testicle.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Pediatric surgeons should provide detailed operative notes for accurate coding.

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.

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.

Reimbursement & Billing Impact

reimbursement processes.

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 undescended testicle accurately?

Accurate coding of undescended testicle is crucial for appropriate treatment planning, monitoring of potential complications, and ensuring proper reimbursement for surgical interventions. It also aids in tracking congenital conditions for public health data.