2025 ICD-10-CM code N48.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the genitourinary system - Diseases of male genital organs (N40-N53) Diseases of the genitourinary system (N00-N99) Feed
Balanitis is inflammation of the glans penis, often accompanied by discomfort and sometimes caused by infection.
Medical necessity for the diagnosis and treatment of balanitis is established by the presence of symptoms (redness, swelling, pain, discharge, itching) and the potential for complications such as phimosis, infection, or scarring.Documentation should clearly link the symptoms, diagnosis, and treatment plan to the patient's clinical presentation.
Diagnosis and treatment of balanitis requires a thorough examination, identification of the causative agent (if infectious), and appropriate management based on the identified cause (e.g., antifungal medication for fungal infections, antibiotics for bacterial infections, hygiene measures, and potentially circumcision).
In simple words: Balanitis is swelling and irritation of the head of the penis.It's more common in men who haven't been circumcised because the skin covering the penis tip can trap moisture and germs. It can be caused by infections, like yeast or bacteria, or by irritation.Symptoms include redness, soreness, and itching. Treatment depends on the cause.
Balanitis refers to inflammation of the glans penis (head of the penis).It commonly affects uncircumcised males due to the moist environment under the foreskin, which facilitates bacterial or fungal overgrowth.Causes include infection (bacterial, fungal, viral, parasitic), irritation from chemicals, poor hygiene, or underlying conditions like diabetes.Symptoms include redness, swelling, soreness, itching, and sometimes discharge. Treatment depends on the cause and may involve antifungal or antibacterial medications, hygiene improvements, and in some cases, circumcision.
Example 1: A 35-year-old uncircumcised male presents with redness, swelling, and pain on the glans penis.He reports poor hygiene practices.Diagnosis: Balanitis due to bacterial infection. Treatment: Topical antibiotic ointment, improved hygiene instructions., A 60-year-old male with diabetes mellitus presents with chronic inflammation and discoloration of the glans penis (Zoon's balanitis). Diagnosis: Zoon's balanitis. Treatment: Topical corticosteroids, meticulous hygiene, and diabetes management., A 10-year-old boy presents with redness, swelling, and a thick, cheesy discharge under his foreskin.Diagnosis: Balanitis secondary to Candida albicans. Treatment: Topical antifungal cream.
Complete history and physical examination, including detailed description of the penile lesions, presence of discharge, and associated symptoms (pain, itching, dysuria).Laboratory testing may be indicated to identify the causative agent (e.g., culture and sensitivity for bacterial or fungal infections). Documentation should support the medical necessity for any prescribed treatments and procedures.
** Balanitis can be a symptom of other conditions, such as sexually transmitted infections (STIs).Proper diagnosis and treatment are essential to prevent complications.Always consult current coding guidelines for the most accurate billing practices.
- Payment Status: Active
- Specialties:Urology, Dermatology
- Place of Service:Office, Outpatient clinic, Urgent Care Facility, Emergency Room - Hospital