Urology Coding Alert

Involving the patient may help you avoid losing out

Recouping reimbursement for an elective vasectomy can be a challenge, but you'll stand a better chance of getting paid if you can show proper authorization for the procedure and pay close attention to individual carrier requirements.

The dilemma: Medicare doesn't cover elective vasectomies at all. And although more private carriers are covering at least a portion of the cost, coders often don't know how to report the procedure to ensure payment.

1. Code CPT 55250 Covers Unilateral, Bilateral Procedures

You should report the vasectomy using 55250 (Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]). The code includes the local or regional anesthesia that the urologist administers.

The urologist usually performs the procedure, which involves cutting the vas deferens and suturing the ends, on both the left and right sides. Because the code descriptor specifies unilateral or bilateral, however, report the procedure the same way whether it's done on one or both sides.

2. Watch for Occasional Laparoscopic Vasectomies

Laparoscopic vasectomies are another option coders may see. These procedures occur most often when a patient requests a vasectomy at the same time he's undergoing a laparoscopic hernia repair, experts say. Since the general surgeon already has the ports and instrumentation in place for the hernia repair, the urologist can perform the vasectomy laparoscopically.

Note: In situations like this, the general surgeon and urologist will likely assist each other. All laparoscopic procedures allow for billing an assistant surgeon, so each physician may charge an assistant fee in addition to reporting his individual procedures.

For the assistant charge, add modifiers 80 (Assistant surgeon) or 82 (Assistant surgeon [when qualified resident surgeon not available]) to the corresponding laparoscopic procedure. But remember that carriers' guidelines will vary, so be sure to check which carriers will reimburse.

There is no CPT Code for laparoscopic vasectomy. For this procedure, you should report 55559 (Unlisted laparoscopy procedure, spermatic cord). "Downgrade to a paper claim, and send a detailed operative report as well as a cover letter explaining the reason for your approach and the details of this technology," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stony Brook. "I would compare or benchmark the laparoscopic vasectomy to 55550 (Laparoscopy, surgical, with ligation of spermatic veins for varicocele), with respect to the surgical work, technology, equipment used, and time involved. Remember to indicate in the cover letter this benchmark determination."

3. Pay Attention to Age, Time Requirements

Although Medicare doesn't reimburse for elective vasectomies, Medicaid does, with a few stipulations. The Medicaid-covered patient must be over 21 years of age, and he must sign a sterilization consent form. And the urologist must wait at least 30 days after the patient signs the authorization form before performing the vasectomy. This 30-day window allows the patient time to change his mind.

Note: Because most Medicare patients are older than 65, vasectomies for Medicare patients are not very common, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis. "Probably 98 to 99 percent of our practice's vasectomies are for non-Medicare patients," he adds.

4. Involve Patient in Carrier Checks

Many private insurance companies are starting to cover elective vasectomies, although they typically require a large out-of-pocket fee that the patient must pay. Elizabeth Hollingshead, CMC, of Conrad Urologic Inc. in Marysville, Ohio, suggests having the patient contact his insurance company to check on his vasectomy reimbursement benefit.

"We always back this up on our end too, but it makes the patient take some responsibility," Hollingshead says. "If they find out that it's not a benefit, it gives them an opportunity to voice their argument with their insurance company instead of our staff."

5. Private Carriers May Ask for Alternative V Code

Determining which V code to report for the pre-vasectomy appointment depends on the carrier. Technically, V25.09 (Encounter for contraceptive management; general counseling and advice; other) is an appropriate code for the exam. You should check with the carrier to see if it prefers V25.2 (Encounter for contraceptive management; sterilization), Hause says. "We've negotiated with almost every one of our payers, and they've asked us to use V25.2 on the initial office visit," he says. "V25.2 more clearly shows why the patient is being seen."
 
Many carriers look at V25.09 as being more applicable to female family planning, Ferragamo says. "If your carrier will accept V25.09, it's a very good code to use as the reason or medical necessity for your consultation, but many carriers look at this as a primarily female ICD-9 diagnostic code, so we're stuck with using V25.2 for both the pre-vasectomy visit and the procedure."

Tip: Another reason to look into V25.2 for the initial exam is that some patients may have coverage from a private carrier for a vasectomy, but not for counseling. Code V25.09 specifies counseling, and the wording may cause some carriers to reject the claim.