2025 ICD-10-CM code N49.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the genitourinary system - Inflammatory disorders of male genital organs Diseases of the genitourinary system (N00-N99) Feed
Inflammatory disorders of the spermatic cord, tunica vaginalis, and vas deferens.
Modifiers may be applicable depending on the circumstances of service, but further investigation on specific billing guidelines are needed.
Medical necessity for coding N49.1 is established by documentation of clinical findings consistent with inflammation of the spermatic cord, tunica vaginalis, or vas deferens.This could involve symptoms (e.g., pain, swelling, tenderness), physical examination findings, and supporting imaging or laboratory data.Treatment decisions should be based on the severity and etiology of the condition.
The clinical responsibility for this code falls on the physician or healthcare professional diagnosing and managing the inflammatory condition.This may involve physical examination, diagnostic testing (such as ultrasound or cultures), and treatment tailored to the specific cause and severity of the inflammation.
In simple words: This code describes inflammation (swelling and irritation) in the tubes and tissues that support the testicles.It may involve the spermatic cord, the sac around the testicles, or the tubes that carry sperm.
This code classifies inflammatory conditions affecting the spermatic cord, tunica vaginalis (the membrane surrounding the testicle), and vas deferens (the tube that carries sperm).It encompasses various inflammatory processes in these structures, potentially including vasitis (inflammation of the vas deferens).
Example 1: A 35-year-old male presents with scrotal pain and swelling.Physical examination and ultrasound reveal inflammation of the spermatic cord and vas deferens, consistent with epididymitis.N49.1 is coded, along with a code specifying the infectious agent (e.g., B96.8 - other bacterial agents)., A 40-year-old male experiences chronic scrotal discomfort and a palpable mass in the spermatic cord.Further investigation reveals inflammation and granulomatous changes in the spermatic cord without an identifiable infectious cause.N49.1 is assigned., A 22-year-old male reports severe scrotal pain following trauma to the region.Examination shows inflammation and swelling of the tunica vaginalis and spermatic cord, suggesting a post-traumatic inflammatory reaction.N49.1 is used.
Complete history and physical examination focusing on the location, duration, and severity of symptoms.Relevant imaging studies (e.g., scrotal ultrasound) should be documented, along with laboratory findings (e.g., complete blood count, urinalysis, and cultures if infection is suspected).Treatment plan and response should also be documented.
** The specific cause of the inflammation should be documented whenever possible, and an additional code may be necessary to specify the infectious agent.This is particularly important for guiding appropriate treatment and management. If the cause is unclear, this code remains accurate but may require further investigation. Remember to always refer to the most current coding guidelines.
- Payment Status: Active
- Specialties:Urology
- Place of Service:Office, Hospital (Inpatient and Outpatient), Urgent Care Facility