What ICD‑10‑CM code should be used for a patient who previously received testosterone injections but has now stopped?

ICD-10-CM Coding for Discontinued Testosterone Therapy

For a patient who previously received testosterone injections but has now stopped, use code Z92.240 (Personal history of steroid therapy, not elsewhere classified).

This is the appropriate ICD-10-CM code to document prior testosterone use that has been discontinued, regardless of whether the therapy was for hypogonadism, gender transition, or other indications.

Key Coding Considerations

• Z92.240 captures the personal history of hormonal therapy including testosterone, which is classified as a steroid medication 1
• This code applies when testosterone therapy has been discontinued and is no longer active treatment 2
• The code documents the clinical history without implying current treatment or ongoing disease 1

Clinical Context That May Influence Additional Coding

• If the patient originally had documented hypogonadism (low testosterone), you may also code E29.1 (Testicular hypofunction) if the underlying condition persists, even though treatment has stopped 3
• If testosterone was stopped due to adverse effects such as erythrocytosis, code the specific complication (e.g., D75.1 for secondary polycythemia) as injectable testosterone causes erythrocytosis in up to 43.8% of patients 1
• If the patient is being monitored for recovery of endogenous testosterone production after cessation, the history code Z92.240 remains appropriate during the monitoring period 4

Important Clinical Pitfalls

• Do not use an active treatment code (such as codes for current drug therapy) once testosterone has been discontinued 2
• Recovery of spermatogenesis after testosterone cessation can take months to years, so the history code remains relevant during this recovery period even if the patient is no longer receiving injections 4
• If testosterone was part of gender-affirming care that has been stopped, Z92.240 is still the appropriate history code, though you may need additional codes to document the gender identity context 5

Documentation Requirements

• Document the indication for original testosterone therapy (hypogonadism, gender transition, etc.) 3
• Record the duration of testosterone use, as prolonged androgen deprivation affects recovery time 4
• Note the formulation used (injectable cypionate/enanthate, gel, patches) as this impacts the timeline for testosterone level recovery 1, 2
• Document the reason for discontinuation (patient preference, adverse effects, fertility concerns, completion of therapy) 4