ICD-10 Coding for Penile Discharge(R36.0, R36.9, A54.09)
Complete ICD-10-CM coding and documentation guide for Penile Discharge. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Penile Discharge
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R36.0 | Urethral discharge without blood | Use when the discharge is non-bloody and no STI is confirmed. |
|
| R36.9 | Unspecified urethral discharge | Use when the discharge is present but not yet specified. |
|
| A54.09 | Gonococcal infection of lower genitourinary tract without periurethral or accessory gland abscess | Use when gonococcal infection is confirmed. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for penile discharge
Essential facts and insights about Penile Discharge
Primary ICD-10-CM Codes for penile discharge
Decision Criteria
clinical Criteria
- Discharge is non-bloody and STI tests are negative
Applicable To
- Non-bloody urethral discharge
Excludes
- Urethral discharge with blood
Clinical Validation Requirements
- Milky urethral discharge without blood
- Negative GC/CT NAAT
Code-Specific Risks
- Misclassification if blood is present
- Inappropriate use without proper lab confirmation
Coding Notes
- Ensure to document the absence of blood and negative STI tests.
R36.9 - Unspecified urethral discharge
Use when the discharge is present but not yet specified.
Applicable To
- Uncharacterized urethral discharge
Excludes
- Specific discharge types
Clinical Validation Requirements
- Penile discharge without further characterization
Coding Notes
Use as a temporary code until further details are available.
A54.09 - Gonococcal infection of lower genitourinary tract without periurethral or accessory gland abscess
Use when gonococcal infection is confirmed.
Applicable To
- Gonococcal urethritis
Excludes
- Gonococcal infection with abscess
Clinical Validation Requirements
- Gram-negative diplococci on smear
- NAAT positive for Neisseria gonorrhoeae
Coding Notes
Ensure lab confirmation before using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for screening for infections with a predominantly sexual mode of transmission
Z11.3Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Penile Discharge to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R36.0.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims or audits.
Mitigation Strategy
Always include a detailed sexual history in the patient record.
Impact
Reimbursement: May lead to incorrect billing and reimbursement issues., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data and statistics.
Mitigation Strategy
Replace R36.9 with specific infection codes like A54.09 when confirmed.
Impact
Incorrect use of STI codes without lab confirmation.
Mitigation Strategy
Require lab results before coding for specific STIs.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Penile Discharge, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Penile Discharge
Use these documentation templates to ensure complete and accurate documentation for Penile Discharge. These templates include all required elements for proper coding and billing.
Urgent Care Visit for Penile Discharge
Specialty: UrologyRequired Elements
- Chief Complaint
- HPI
- Sexual History
- Physical Exam
- Diagnostic Results
- Assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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