Urology Coding Alert

Question: A primary care physician referred a patient to our urologist for an undescended testicle. Upon examination, the physician found that the testicle was not undescended. How should we code this examination, and which diagnosis is correct?

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Answer: This clinical scenario, common in pediatrics, most likely represents a retractile testicle, a normally descended testicle with a cremasteric reflex that pulls the testicle into the inguinal canal, mimicking the absence of a scrotal testicle. You should code the described encounter as a consultation (99241-99245) with the diagnosis of retractile testicle 752.52 (Congenital anomalies of genital organs; undescended and retractile testicle; retractile testis). Another secondary diagnosis may be V71.89 (Observation and evaluation for suspected conditions not found; observation for other specified suspected conditions; other specified suspected conditions) because the suspected condition undescended testicle was not found. The pediatrician who discovered the problem and referred the patient to the urologist will bill the symptom 752.51 (Undescended testis).