Pathology/Lab Coding Alert

Don’t settle for ‘total’ and ‘free’ coding options.

If your lab has been struggling with the question of how to handle orders for bioavailable testosterone while CPT® provides no code for the test, your waiting is over.

CPT® 2017 introduces 84410 (Testosterone; bioavailable, direct measurement [e.g., differential precipitation]) to fill the coding gap.

Prior to the addition, you’ve had just the following two codes to describe testosterone testing:

• 84402 — Testosterone; free
• 84403 — … total

You might have used 84402 and 84403 to report the assay if you tested free, total and perhaps other analytes such as Sex Hormone Binding Globulin (SHBG) to calculate a value for bioavailable testosterone. But if your lab performed a direct measure of bioavailable testosterone, you had no choice but to report unlisted code 84999 (Unlisted chemistry procedure).

Read on to see how the new code fits into the existing code family, and what it might mean for your lab’s bottom line.

Distinguish Analyte and Method to Choose Proper Code

Testosterone circulating in the blood is primarily bound to SHBG, and to a lesser extent to albumin, while a small portion circulates as free hormone. Clinicians initially thought that the free hormone constituted the biologically active fraction, but further study indicates that the albumin-bound fraction is freely released, and therefore also represents a portion of testosterone that is available for uptake in surrounding tissue. That means the “bioavailable” testosterone is free plus albumin-bound — which is equivalent to non-SHBG bound.

With this shift in understanding, more and more clinicians desire a measure of bioavailable testosterone, because “it provides the best measure of testosterone that is active in the body,” explains William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Three test methods: You should understand a bit about the common direct-measure test methods for the three testosterone tests to help you choose the right code:

• Total — Labs typically use a heavy-hydrogen-labeled testosterone standard in a serum specimen, then perform various steps resulting in a quantitative total testosterone measure by an instrument such as a liquid chromatograph/tandem mass spectrometer (LC-MS/MS).
• Free — Labs may determine percentage free testosterone in serum using a semipermeable membrane to separate free and SHBG-bound testos­terone, then multiply the percentage by the total testosterone measured by LC-MS/MS.
• Bioavailable — The lab analysis involves differential precipitation of SHBG with ammonium sulfate and quantification of the non-SHBG (bioavailable) fraction based on a relationship between measured SHBG and total testosterone.

Look for Payment Impact

CMS’s preliminary 2017 payment recommendation for bioavailable testosterone is to crosswalk 84410 to 84402 plus 84403, based on recommendations made at the Clinical Laboratory Fee Schedule (CLFS) Annual Laboratory Public Meeting held earlier this year.

New code 84410 “involves calculation and measurement of free and total testosterone and [uses] similar resources,” stated Ronald McLawhon, MD, PhD, representing the College of American Pathologists at the public meeting in support of a crosswalk to 84402 plus 84403.

In contrast, Paul Sheives, representing the American Clinical Laboratory Association (ACLA) at the public meeting suggested a crosswalk to 84403x3 because the test involves “performing the testosterone assay three different times on three different samples.”

Watch for bundling: Although CPT® does not provide a text note curtailing your ability to report 84410, 84402, and 84403 together when your lab performs and reports all three tests, “We’ll need to pay attention to see if the National Correct Coding Initiative (CCI) creates edit pairs for these codes,” Dettwyler says.

Understand Medical Necessity

Testosterone is hormone crucial for normal sexual development in men and women. The adrenal gland, testes in men, and ovaries in women produce the hormone.

Clinicians may order total testosterone as a first-tier test to evaluate many conditions related to possible abnormal testosterone levels in males, such as delayed or early puberty, enlarged breasts, osteoporosis, or infertility; as well as possible abnormal testosterone levels in females, such as male-pattern hair growth and muscle development, and lackof menstrual periods. Clinicians may also order this test to evaluate possible testosterone-secreting tumors, or to monitor testosterone replacement therapy or anti-testosterone therapy for conditions such as prostate cancer.

To further assess abnormal testosterone levels, or to evaluate patients with suspected or known SHBG anomalies, clinicians may request either bioavailable or free testosterone testing. Other common reasons that clinicians order this testing is to evaluate symptomatic patients with normal total testosterone, or to monitor testosterone therapy in older men or females. Because physicians often use free or bioavailable testosterone measures for the same indications, you won’t often see the two tests ordered together.