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Home/Diagnosis/ICD-10 Coding for Penile Discharge

ICD-10 Coding for Penile Discharge

R36.0
R36.9
A54.09

Complete ICD-10-CM coding and documentation guide for icd-10 coding for penile discharge includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Urethral Discharge
Male Genital Discharge
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Key Information: ICD-10 Coding for Penile Discharge

Essential facts and insights about ICD-10 Coding for Penile Discharge

Use ICD-10 code R36.0 for urethral discharge without blood, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Urethral discharge without blood

Billable Code
R36.0
Billable

Diagnostic Criteria

  • • Discharge is non-bloody and STI tests are negative

Applicable To

  • • Non-bloody urethral discharge

Important Notes

  • • Ensure to document the absence of blood and negative STI tests.

Unspecified urethral discharge

Billable Code
R36.9
Billable

Diagnostic Criteria

  • • Penile discharge without further characterization

Applicable To

  • • Uncharacterized urethral discharge

Important Notes

  • • Use as a temporary code until further details are available.

Gonococcal infection of lower genitourinary tract without periurethral or accessory gland abscess

Billable Code
A54.09
Billable

Diagnostic Criteria

  • • Gram-negative diplococci on smear
  • • NAAT positive for Neisseria gonorrhoeae

Applicable To

  • • Gonococcal urethritis

Important Notes

  • • Ensure lab confirmation before using this code.
Ancillary Codes

Additional codes that may be used with this diagnosis

Z11.3

Encounter for screening for infections with a predominantly sexual mode of transmission

Use when screening for STIs is performed.

Frequently Asked Questions

What is the ICD-10 code for penile discharge?

The ICD-10 code for unspecified penile discharge is R36.9, while R36.0 is used for non-bloody discharge. Specific codes like A54.09 are used for confirmed infections.

How do you document penile discharge?

Document penile discharge by noting its color, consistency, presence of blood, and any associated symptoms. Include sexual history and lab results for accurate coding.

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