Fracture of corpus cavernosum penis, initial encounter

This code signifies a traumatic rupture or break in the tunica albuginea surrounding the erectile tissue (corpus cavernosum) of the penis. This injury typically occurs during vigorous sexual activity or direct trauma, leading to a sudden loss of erection, pain, and often a "snapping" sound.

Apply this code for the initial presentation and active treatment of a patient diagnosed with a penile fracture. This includes emergency department visits, initial surgical repair, or the first encounter where the diagnosis is established and a treatment plan is initiated.

• Always confirm the "initial encounter" status for this code. Subsequent encounters for follow-up care or complications will require a different seventh character.
• Look for documentation of a sudden event, acute pain, detumescence, and often ecchymosis or hematoma formation consistent with penile fracture.
• Consider additional codes for associated injuries or complications, such as urethral involvement, if documented.