Find comprehensive information on varicocele diagnosis including clinical documentation, medical coding, ICD-10 codes (N43.4), CPT codes for varicocelectomy (55560, 55562), and ultrasound imaging. Learn about symptoms, treatment options, and post-operative care for varicocele. This resource provides healthcare professionals with accurate and relevant information for proper diagnosis and billing related to varicocele.
Also known as
Diseases of male genital organs
Covers conditions affecting the male reproductive system.
Diseases of veins, lymphatic vessels
Includes various vein and lymphatic system disorders.
Symptoms and signs involving skin
Encompasses visible skin changes and related symptoms.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the varicocele symptomatic?
When to use each related code
| Description |
|---|
| Enlarged veins in scrotum |
| Fluid collection in scrotum |
| Testicular torsion |
Missing or incorrect laterality (right, left, bilateral) for varicocele impacts reimbursement and data accuracy. CDI can query for clarity.
Coding symptoms like scrotal pain instead of the confirmed diagnosis of varicocele leads to underreporting and inaccurate clinical data.
Using unspecified codes when a more specific diagnosis (e.g., primary, secondary) is documented impacts quality reporting and payment.
Patient presents with complaints consistent with varicocele symptoms, including scrotal pain, testicular pain, or a feeling of heaviness or fullness in the scrotum. Physical examination reveals a palpable, non-tender mass described as a "bag of worms" in the left scrotum, consistent with a clinical diagnosis of varicocele. The right scrotum is unremarkable. Differential diagnoses considered include spermatocele, hydrocele, and inguinal hernia. Assessment includes evaluation for male infertility, as varicoceles can impact sperm production. Treatment options discussed include watchful waiting, varicocele embolization, and varicocelectomy. Patient education provided regarding varicocele causes, varicocele grading (Grade I, Grade II, Grade III), and potential complications such as testicular atrophy and infertility. Patient understands risks and benefits of each treatment option and will follow up for further evaluation. ICD-10 code N45.40 (Varicocele of unspecified testicle) and relevant CPT codes for procedures, if performed, will be documented. This documentation supports medical necessity for evaluation and management of varicocele and any subsequent interventions.