Urology Coding Alert

Vasectomy coding can be complicated by one simple fact: Managed-care companies arent always ready to pay for it. Medicare doesnt cover vasectomies at all. And while many private health plans are willing to pay for vasectomies, some are not. Brenda Oliver, billing office manager for Pioneer Valley Urology, a six-urologist practice in Springfield, Mass., explains the four steps to coding vasectomies.

1. Sending a consent form and waiver. Before the patient even comes in for the visit, Olivers office sends him a vasectomy package. This includes a consent form and a brochure describing the procedure and its effects. The consent form is very important, says Oliver. When the patient comes in for the first visit, he brings the form, which has been signed by him and his wife. We need the wifes signature on the consent form too because when we didnt have it, sometimes the wife would come in later and say, I didnt know he had this, says Oliver. These women would be very upset, thinking that they had been tricked into not having any more children. It got to be so difficult for the office that the wifes consent was required.

Now, because of the problem with some insurance companies not paying for vasectomies at all, Oliver is adding a waiver to the packet. The exact wording of the waiver hasnt been determined yet, but it will tell the patient to tell the insurance company that he is going to have a vasectomy. Were going to tell them the code 55250 and tell them to talk to the insurance company to find out about payment, says Oliver. Its supposed to be the patients responsibility, and we are going to make it that.

The office used to call insurance companies after the patients first visit to find out if vasectomies were covered. Wed spend a lot of time on hold with the insurance companies, she says. It was very time consuming, and thats why were starting the new policy with the waiver.

The waiver language itself also will cover a situation in which a patient may think the insurance company will pay, but the company really wont. It will say something along the lines of, If for some reason my insurance company rejects the claim, I understand that I am responsible for the bill, says Oliver.

2. Coding the first visit. The first visit is either a consultation (99241-99245) or, more likely, a new patient office visit (99201-99205). It also could be an established patient office visit (99212-99215) if he has been seen by the urologist within the past three years. Oliver uses diagnosis code V25.2 (encounter for contraceptive management; sterilization) for the initial visit (consult or office visit) and for the vasectomy itself.

Note: The initial visit may be a consultation when the criteria for consultations are met. Generally, however, the patient self-refers or is referred by his or her primary-care provider, in which case the visit would be an office visit.

During this visit, the urologist discusses the procedure with the patient and, sometimes, the patients wife. The urologist explains what the procedure entails and answers any questions he may have. Also during this visit, the patient watches a short video about vasectomies.

In the past, explains Oliver, the urologist might see the patient for the first time and do the vasectomy on the same day. But sometimes the patient would change his mind and decide he didnt want the procedure after all, says Oliver. Then youd have a half-hour gap in the schedule. So in the long run, its much better to do the visit (whether its a consultation or a new patient visit) first and then to schedule the procedure for another day.

3. Coding the procedure. The procedure, which takes about half an hour in the office, is coded 55250 (vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]). It involves cutting the vas deferens and suturing the ends. The procedure is done under local or regional anesthesia; the anesthesia is included in the code (as per the surgery guidelines in CPT 2000, which, under listed procedures, states that surgical procedures include ... local infiltration). Usually the procedure is repeated on both sides, but because the code descriptor says unilateral or bilateral, whether you perform the procedure on one or both sides is immaterial to the code.

Medicare will not pay for a vasectomy when it is done for contraceptive purposes. Medicare will, however, pay for a vasectomy when there is pathologic evidence that sterilization is a necessary part of the treatment of an illness or injury.

There are many disease processes that might call for a vasectomy that Medicare would reimburse. Chronic epididymitis is one possibility (ICD-9 code 604.90).

When a vasectomy is performed for contraceptive purposes only, if the patient is covered by Medicare, the patient must sign a waiver and pay for the procedure himself, says Oliver.

There is also a surgical tray for which you can bill, says Oliver. Use HCPCS code A4550 (surgical trays) or CPT code 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]). Usually, Oliver uses A4550.

Medicare and Medicaid have published the allowable for HCPCS code A4550, explains Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a billing, reimbursement and compliance company in Denver. HCFA has established an RVU of 0.52 that is paid as part of the physicians fee scheduleits about $20, says Page. Private payers frequently will establish payment for a small trayabout $25for minor procedures such as lesion removal, and a large trayabout $30 to $50for more significant procedures such as a biopsy tray with a Huber needle.

4. Coding the semen analysis. After the vasectomy, the semen must be tested for sperm. Otherwise, you wont know if some sperm are still left. Even though the vasectomy descriptor clearly includes post-vasectomy semen testing, it doesnt say how many tests need to be done, or how many the 55250 code includes.

The physician usually does two, says Mark Cendron, MD, associate professor of urology and pediatrics at Dartmouth Hitchcock Medical Center in Lebanon, N.H. Its hard to justify more than two. It takes, at most, 100 days for sperm to get through the system, he says. Therefore, if you do a semen analysis one month after the vasectomy, and find no sperm, you dont need to do another analysis. If there are some sperm, you should do another semen analysis three months after the procedureand then, there should be no sperm.

Sometimes, however, the vas may recanalize. The urologist may have cut it, but it grows back. At this point there may still be sperm. This is why urologists want to make sure both samples are free of sperm.

Olivers practice does the first analysis two months after the procedure, and another one after that. The physician wants two negative samples, she says.

Is it possible to bill separately for the semen analysis? Yes, says Oliver. Most insurance companies will pay for the semen analyses, although some do say its part of the global, she says. Usually, Blue Cross/Blue Shield wont pay, but others will. She uses code 89310 (semen analysis; motility and count).

You cannot bill for an office visit when the patient comes in for the follow-up semen analyses, notes Page.

Related office visits within the global are never paid separately, she says. Global for 55250 depends on the payer, she adds. Medicare has a 90-day global, and I have seen 30-day globals for other payers. Oliver uses diagnosis code V25.8 (encounter for contraceptive management; other specified contraceptive management) for the semen analyses.