Revenue Cycle Insider

Question: A patient presented to the urologist with complaints of pain while urinating, pain in the lower right abdominal quadrant, and pain in the right side of the scrotum. The pain is worse on exertion. The urologist completes a history of present illness, performs a physical examination, and collects a urine sample. The patient also underwent an ultrasound in-house. After reviewing the results, the urologist diagnoses the patient with epididymo-orchitis.

What is this condition and how do I report it?

Florida Subscriber

Answer: Assign N45.3 (Epididymo-orchitis) to report the patient’s condition. To locate the code, you’ll open the ICD-10-CM Alphabetic Index and search for Epididymo-orchitis, which provides you with the code and also instructs you to “see also Epididymitis.” Under Epididymitis > with orchitis, you’ll also find N45.3. Turn to the Tabular List to verify the code.

ID the infection: Parent code N45.- (Orchitis and epididymitis) features a Use additional code note instructing you to assign a code from B95.- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) to B97.- (Viral agents as the cause of diseases classified elsewhere) to identify the infection, if it is documented.

Epididymo-orchitis is a condition where the patient experiences inflammation in the epididymis and the testicle due to an infection. The epididymis is a coiled tube at the back of the testicle that stores and carries sperm from the testicle.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC