Find information on Testosterone Deficiency diagnosis, including clinical documentation, medical coding (ICD-10, SNOMED CT), symptoms, treatment, and lab tests. Learn about hypogonadism, low testosterone levels, male andropause, and hormone replacement therapy. Explore resources for healthcare professionals on diagnosing and managing testosterone deficiency in men. This resource covers relevant medical terms for accurate documentation and coding related to androgen deficiency.
Also known as
Testicular dysfunction
Covers male hypogonadism and testosterone deficiency.
Delayed puberty, male
May be related to testosterone deficiency if puberty is significantly delayed.
Chromosomal abnormalities
Certain genetic conditions can cause testosterone deficiency.
When to use each related code
Description |
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Low testosterone levels in men. |
Late-onset hypogonadism. |
Klinefelter syndrome (47,XXY). |
Coding with unspecified testosterone deficiency (e.g., E29.1) without documented clinical support for a more specific code creates audit risk.
Insufficient documentation of symptoms, exam findings, and lab results supporting medical necessity for testosterone testing and treatment poses compliance and coding risks.
Miscoding age-related decline in testosterone (normal aging) as hypogonadism (e.g., E29.1, D29.1) leads to inaccurate coding and potential denial of claims.
Patient presents with symptoms suggestive of testosterone deficiency (hypogonadism), including fatigue, decreased libido, erectile dysfunction, and reduced muscle mass. He reports a gradual onset of these symptoms over the past year. Review of systems reveals difficulty concentrating, depressed mood, and decreased energy levels. Past medical history is significant for hypertension, managed with lisinopril. Family history is noncontributory. Physical examination reveals normal testicular size and no gynecomastia. Initial laboratory evaluation includes a morning serum total testosterone level, free testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Differential diagnosis includes primary hypogonadism, secondary hypogonadism, and age-related decline in testosterone. Based on the patient's clinical presentation and pending laboratory results, the current assessment is consistent with possible male hypogonadism. A treatment plan will be formulated following review of laboratory data and may include testosterone replacement therapy (TRT), lifestyle modifications such as diet and exercise, and management of comorbid conditions. Patient education will address the benefits and risks of testosterone therapy, potential side effects, and the importance of follow-up monitoring of testosterone levels, hematocrit, and prostate-specific antigen (PSA). ICD-10 code E29.1 (Testicular hypofunction) or E23.0 (Hypogonadotropic hypogonadism) may be applicable depending on laboratory results. CPT codes for laboratory testing and follow-up visits will be documented accordingly. The patient was advised to return for follow-up in four weeks to review laboratory results and discuss treatment options.