ICD-10 Codes for Sperm Count Check and Urology Evaluation
For a sperm count check and urology evaluation, use ICD-10 code N46.9 (Male infertility, unspecified) or Z31.41 (Encounter for fertility testing) as the primary diagnostic code, depending on whether infertility is suspected or this is purely screening.
Primary ICD-10 Codes for Sperm Count Testing
N46.9 - Male infertility, unspecified is the most appropriate code when:
- The patient has concerns about fertility potential 1
- The couple has not achieved conception after one year of unprotected intercourse 1
- Male infertility risk factors exist (history of cryptorchidism, varicocele, etc.) 1
Z31.41 - Encounter for fertility testing should be used when:
- The patient requests fertility evaluation without a current partner 1
- This is a screening evaluation before attempting conception 2
- No specific infertility diagnosis has been established 2
Additional Specific ICD-10 Codes Based on Clinical Findings
If the initial evaluation reveals specific abnormalities, use more precise codes:
For oligospermia (low sperm count):
- N46.11 - Organic oligospermia 3
- N46.121 - Oligospermia due to drug therapy 4
- N46.129 - Oligospermia due to other extratesticular causes 4
For azoospermia (absent sperm):
- N46.01 - Organic azoospermia 4
- N46.021 - Azoospermia due to drug therapy 4
- N46.029 - Azoospermia due to other extratesticular causes 4
For hormonal abnormalities identified during workup:
- E29.1 - Testicular hypofunction (if low testosterone with elevated FSH/LH) 4
- E23.0 - Hypopituitarism (if low testosterone with low/normal FSH/LH) 4
Essential Components of the Urological Evaluation
The comprehensive evaluation should include 1:
Reproductive history assessment:
- Frequency and timing of intercourse 1
- Duration of current infertility 1
- Prior fertility history 1
- Sexual history including sexually transmitted diseases 1
- Gonadal toxin exposure including heat 1
Physical examination findings that determine coding:
- Testicular volume measurement (normal >15 mL; small testis suggests N46.01) 1
- Presence of varicocele (use I86.1 as secondary code) 1
- Congenital bilateral absence of vas deferens (use Q55.4) 1
- Cryptorchidism history (use Z87.710 for personal history) 1
Laboratory testing requirements:
- At least two semen analyses performed one month apart 1, 2
- Serum testosterone and FSH if sperm concentration <10 million/mL 2
- Genetic testing (karyotype, Y-chromosome microdeletions) for severe oligospermia (<5 million/mL) or azoospermia 1, 4, 2
Common Pitfalls in ICD-10 Coding for Male Infertility
Avoid using N46.9 when more specific codes apply: If semen analysis reveals oligospermia or azoospermia, use the specific subcategory codes (N46.11 or N46.01) rather than the unspecified code 4.
Document secondary diagnoses that affect fertility: Conditions like varicocele (I86.1), hypogonadism (E29.1), or history of cryptorchidism (Z87.710) should be coded separately as they impact treatment decisions and prognosis 1, 4.
Use Z31.41 appropriately for screening: This code is specifically for fertility testing encounters and should not be used if infertility has already been diagnosed 2.
Consider metabolic comorbidities: Men with low sperm counts have 12-fold increased risk of hypogonadism and higher prevalence of metabolic syndrome, so additional codes for obesity (E66.-), hypertension (I10), or dyslipidemia (E78.-) may be warranted 3.
Coding for Follow-Up Evaluations
For repeat semen analysis: Continue using the same primary code (N46.9, N46.11, or N46.01) with modifier indicating this is a subsequent encounter 1, 2.
For advanced testing: If sperm DNA fragmentation or oxidative stress testing is performed, maintain the primary infertility code while documenting the specific indication 5.
For genetic testing encounters: Use Z31.430 (Encounter for genetic testing of male for procreative management) as a secondary code when performing karyotype or Y-chromosome microdeletion analysis 1, 4, 2.