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v1.0.0
ICD-10 Guide
ICD-10 CodesQ54.8

Q54.8

Billable

Other hypospadias

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

Code Description

ICD-10 Q54.8 is a billable code used to indicate a diagnosis of other hypospadias.

Key Diagnostic Point:

Hypospadias is a congenital malformation of the male urethra characterized by an abnormal opening of the urethra on the ventral surface of the penis, rather than at the tip. The severity of hypospadias can vary, with the location of the urethral opening ranging from the glans to the scrotum. 'Other hypospadias' encompasses cases that do not fit into the more common classifications of distal or proximal hypospadias. This condition can be associated with other genital anomalies, such as cryptorchidism (undescended testicles) and ambiguous genitalia. The etiology of hypospadias is multifactorial, involving genetic, hormonal, and environmental factors. Diagnosis is typically made at birth during a physical examination, and management may involve surgical correction to reposition the urethral opening and ensure normal urinary function and cosmetic appearance. Early intervention is crucial to prevent complications such as urinary obstruction, recurrent urinary tract infections, and psychological distress related to genital appearance.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of hypospadias.
  • Potential association with other congenital anomalies.
  • Need for precise documentation of the location of the urethral opening.
  • Differentiation from other similar conditions such as epispadias.

Audit Risk Factors

  • Inadequate documentation of the specific type of hypospadias.
  • Failure to document associated congenital anomalies.
  • Incorrect coding of surgical procedures related to hypospadias.
  • Misclassification of hypospadias severity.

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed physical examination findings, including the location of the urethral opening and any associated anomalies.

Common Clinical Scenarios

Newborns presenting with hypospadias, cases requiring surgical intervention, and follow-up visits post-surgery.

Billing Considerations

Consideration of the psychological impact on the child and family, as well as the need for potential referral to urology.

Genetics

Documentation Requirements

Family history of congenital anomalies, genetic testing results if applicable, and any syndromic associations.

Common Clinical Scenarios

Cases where hypospadias is part of a genetic syndrome, such as Turner syndrome or Klinefelter syndrome.

Billing Considerations

Understanding the genetic implications and counseling families about recurrence risks.

Coding Guidelines

Inclusion Criteria

Use Q54.8 When
  • Follow the official ICD
  • CM coding guidelines for congenital malformations, ensuring accurate documentation of the condition's specifics, associated anomalies, and any surgical interventions performed

Exclusion Criteria

Do NOT use Q54.8 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

54300CPT Code

Urethroplasty for hypospadias repair

Clinical Scenario

Used in cases of surgical correction of hypospadias.

Documentation Requirements

Document the type of hypospadias and details of the surgical procedure.

Specialty Considerations

Urology specialists typically perform this procedure.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of hypospadias, improving the accuracy of data collection and reimbursement processes. Coders must be familiar with the nuances of the new codes to ensure proper billing.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hypospadias, improving the accuracy of data collection and reimbursement processes. Coders must be familiar with the nuances of the new codes to ensure proper billing.

Reimbursement & Billing Impact

reimbursement processes. Coders must be familiar with the nuances of the new codes to ensure proper billing.

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 is the difference between hypospadias and epispadias?

Hypospadias is characterized by the urethral opening being located on the underside of the penis, while epispadias involves the urethral opening being located on the upper side. Both are congenital conditions but require different coding and management approaches.