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ICD-10 Guide
ICD-10 CodesR86.5

R86.5

Abnormal microbiological findings in specimens from male genital organs

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

Code Description

ICD-10 R86.5 is a billable code used to indicate a diagnosis of abnormal microbiological findings in specimens from male genital organs.

Key Diagnostic Point:

R86.5 is used to classify abnormal microbiological findings in specimens obtained from male genital organs, which may include urine, semen, or tissue samples. These findings can indicate the presence of infections, inflammatory conditions, or other pathological processes. Common symptoms associated with these findings may include dysuria, penile discharge, or scrotal pain. Laboratory tests may reveal the presence of bacteria, fungi, or viruses that are not typically found in healthy specimens. The clinical context is crucial, as abnormal findings can lead to further diagnostic investigations to determine the underlying cause, such as sexually transmitted infections (STIs), prostatitis, or other urogenital disorders. Accurate coding requires a thorough understanding of the clinical scenario and the specific findings reported in laboratory results.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying conditions
  • Need for precise documentation of laboratory findings
  • Differentiation from other similar codes
  • Potential overlap with other diagnoses

Audit Risk Factors

  • Inadequate documentation of laboratory results
  • Failure to specify the type of abnormal finding
  • Misclassification of findings as normal
  • Inconsistent coding across different encounters

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of patient history, symptoms, and laboratory findings is essential. Include specific results from microbiological tests.

Common Clinical Scenarios

Patients presenting with urinary symptoms, pelvic pain, or abnormal discharge.

Billing Considerations

Consider the patient's sexual history and risk factors for STIs when coding.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate findings and any interventions performed.

Common Clinical Scenarios

Patients with acute scrotal pain or severe dysuria requiring urgent evaluation.

Billing Considerations

Rapid assessment and documentation of findings are critical in emergency settings.

Coding Guidelines

Inclusion Criteria

Use R86.5 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when there is clear documentation of abnormal microbiological findings from male genital organs
  • Ensure that the findings are not classified elsewhere

Exclusion Criteria

Do NOT use R86.5 When
No specific exclusions found.

Related CPT Codes

87070CPT Code

Culture, bacterial, any source

Clinical Scenario

Used when a culture is performed to identify abnormal findings.

Documentation Requirements

Document the source of the specimen and the findings.

Specialty Considerations

Ensure that the procedure is linked to the diagnosis of abnormal findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the granularity of data collection and analysis in male genital health.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the granularity of data collection and analysis in male genital health.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the granularity of data collection and analysis in male genital health.

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 types of findings are classified under R86.5?

R86.5 includes any abnormal microbiological findings from male genital specimens, such as bacteria, fungi, or viruses that indicate an infection or other pathological condition.