Epispadias

This code represents a congenital malformation of the urethra where the opening is located on the dorsal (upper) aspect of the penis in males, or the clitoris/pubic symphysis in females. It is a rare anomaly resulting from incomplete fusion of the urethral folds.

Use this code when documentation clearly indicates a diagnosis of epispadias, regardless of gender. This diagnosis is typically made at birth or early childhood and often requires surgical correction. Supporting documentation would include physician notes detailing the anatomical location of the urethral meatus.

• Always ensure the documentation specifies the dorsal urethral opening to differentiate from other urethral anomalies.
• Remember the Excludes1 note for hypospadias (Q54.-); these conditions are never coded together.
• Look for associated congenital anomalies, as epispadias can be part of a broader malformation complex like bladder exstrophy.