Urology Coding Alert

Like most fertility treatments, vasectomy reversal 55400 (vasovasostomy, vasovasorrhaphy) is not generally payable under most insurance plans. Neither is counseling regarding the problem. And the counseling can be time-consuming: Often the patient and his wife are with the physician for as much as an hour talking about options. But there are other procedures which do restore male fertility. To get paid for these, however, you will probably have to make sure that the procedure is done for medical reasons.

A vasectomy reversal is not medically necessary, notes Jackie Shovan, CPC, financial counselor with the division of urology at the University of Utah. Infertility is not detrimental to the patients health, and insurance companies arent going to pay you to help your patients have more children.

Blockages do cause infertility and repairing them may be reimbursable, providing the procedure is done for a medical reason (such as pain relief) and not to restore fertility. However, vasectomy reversal is only done for one purpose: restoration of fertility. The diagnosis code alone, 606.9 (male infertility unspecified), would be a tip-off to the insurance company that the procedure would be excluded.

The procedure itself is always elective, agrees Karen Imamura, office manager for Tower Urology Medical Group of Los Angeles, CA. That means there is no point in trying to prove medical necessity. Its unfortunate and ironic, because vasectomy reversal has a high success rateover 85 percent in Imamuras practice. Couples are, of course, happy to hear this, because at least it means that the money that they pay out of pocket100 percent of the feewill most likely be invested in a pregnancy.

If the patient has insurance, and its with a plan we are contracted with, we get a waiver, such as you would use for Medicare, which allows you to bill the patient for a procedure that is not covered by the plan.

Tip: When the patient makes an appointment to discuss vasectomy reversal, you need to investigate over the phone whether the procedure is covered. Occasionally it is, depending on the plan.

Diagnosis Codes for Varicoceles
and Sperm Granulomas

Since using an infertility diagnosis (606.9) will almost always result in non-payment by the insurance carrier, its important not to use that code when a procedureor a consultationis being done for a different clinical reason, even if the procedure will result in restoration of fertility.

- Varicoceles. A varicocele occurs when the veins of the spermatic cord are dilated. Varicoceles can be very painful and must be repaired by ligation of the veins or excision of the varicocele itself. When these are excised (55530 [excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)] 55535, [abdominal appraoch]), pain is relieved. The procedure is done for medical purposes, rather than for treatment of infertility. But the fact that there was a blockage often resulted in infertility, so the excision restores fertility. Will insurance pay for this procedure? Yes, but the carrier may well be suspicious if a semen analysis was done prior to the procedure, says Shovan. The carrier will ask for background, she says. If they find that the patient had a semen analysis, the insurance company may say the only reason the procedure was done was for infertility, and deny the claim. This shows that you must be very careful with diagnosis codes and supporting documentation. The case must be clearly documented to show that the procedure is medically necessary, regardless of any concomitant effects regarding fertility.

- Sperm granulomas. Vasovasostomy code (55400) is also used for excisions of sperm granulomas ICD-9 608.89, says Imamura. After a vasectomy, there is sometimes a granuloma that remains; sperm may crystallize and become painful. A vasovasostomy cures the condition and also restores fertility in many cases.

Payment for Consultations

What about getting reimbursed for the hour spent talking to the post-vasectomy patient who wants a reversal? The reports are mixed here. Stella Natarova, CPC, CCS-P, director of compliance and reimbursement for Adult and Pediatric Urology Group of Maryland in Baltimore, recommends using V26.52 (procreative management; sterilization status; vasectomy status) if your carrier will pay it. Dont automatically use an infertility diagnosis, she says. Infertility is rarely covered, and you dont even know if the patient is there for infertility. It may be just for the consultation
[99241-99245].

Tip: Some insurers wont pay with a V code used as the primary diagnosis. In these cases, you would have to use the diagnosis code for infertility. But as Imamura says, V26.52 is certainly worth a try, at least for the consultation.

The consultation (or office visit, if the patient came directly to you without a referral) can be billed based on time, if 50 percent or more of the time spent on the encounter is counseling and/or coordination of care. This is important in the discussion of fertility restoration in a post-vasectomy patient, as a lot of time is usually involved. Follow CPT guidelines on time (e.g., Physicians typically spend XX minutes face-to-face with the patient and/or family) and document the extent of counseling in the medical record. You should do this even if the visit is going to be self-pay.