ICD-10-CM Code for Phimosis: Complete Guide
Phimosis is a common urological condition affecting males, where the foreskin of the penis cannot be fully retracted over the glans. While it can be a normal finding in young children, persistent or pathological phimosis may require medical evaluation and treatment. For healthcare providers and medical coders, it’s essential to assign the correct ICD-10-CM code to ensure accurate documentation, billing, and treatment tracking.
In this guide, we break down what phimosis is, how it's categorized, and the correct ICD-10-CM codes to report.
What Is Phimosis?
Phimosis refers to the inability to retract the foreskin (prepuce) over the head of the penis. It can be either:
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Congenital (physiological) – present at birth and often resolves naturally during childhood.
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Acquired (pathological) – develops later in life due to scarring, inflammation, or infection.
Phimosis may present with symptoms like:
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Painful urination
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Ballooning of the foreskin during urination
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Recurrent infections (balanitis)
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Discomfort during erections or sexual activity
In more severe cases, it can lead to complications such as urinary retention or paraphimosis, which may require surgical intervention.
ICD-10-CM Codes for Phimosis
ICD-10-CM provides distinct codes for congenital and acquired phimosis
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This code is used when the patient has phimosis that is present from birth
Use N47.0 if:
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The provider documents congenital or physiological phimosis
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The condition is not caused by infection or trauma
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The patient is a child with no other underlying cause
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This code is used when phimosis develops later in life
Use N47.1 if:
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There is mention of recurrent balanitis or post-inflammatory changes
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The foreskin has become non-retractable over time
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The provider documents it as "pathological" or "acquired"
Additional Related Codes (if applicable)
Sometimes, phimosis may appear with or lead to other conditions. Here are related codes to consider based on clinical documentation:
| Condition | ICD-10-CM Code |
|---|---|
| Balanitis | N48.1 |
| Balanoposthitis | N48.89 |
| Paraphimosis | N47.2 |
| Other disorders of the penis | N48.89 |
| Circumcision encounter | Z41.2 |
Clinical Documentation Tips for Accurate Coding
To ensure correct ICD-10-CM code assignment:
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Specify whether the phimosis is congenital or acquired
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Document any underlying causes (e.g., infections, scarring)
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Note associated symptoms or complications (e.g., urinary issues, pain)
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Include planned procedures like circumcision or topical treatments
Example Coding Scenarios
Pediatric Case:
A 4-year-old male presents with non-retractable foreskin. No pain or infection. The provider documents “congenital phimosis.”
1. Code: N47.0 – Congenital phimosis
Adult Case:
A 35-year-old male has difficulty retracting the foreskin with pain and history of chronic balanitis. Diagnosis: “acquired phimosis due to post-inflammatory scarring.”
2.Code: N47.1 – Acquired phimosis
When Is Treatment Needed?
Not all cases of phimosis require surgery. Depending on severity, treatment may include:
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Topical corticosteroids
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Gentle stretching exercises
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Circumcision (especially in recurrent or severe cases)
Medical necessity documentation is important if procedures like circumcision are performed, especially in adult patients.
Final Thoughts
Accurately coding for phimosis ensures proper clinical documentation and reimbursement. Distinguishing between congenital and acquired
Quick Reference:
| Type of Phimosis | ICD-10-CM Code |
|---|---|
| Congenital | N47.0 |
| Acquired | N47.1 |
| Paraphimosis | N47.2 |