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Urology Coding Alert

Impotence:

Payment Differs for Workups

Published on Mon Oct 01, 2001

When a patient complains of erectile dysfunction, the urologist must choose a diagnosis code carefully to be paid for the visit. Organic impotence (607.84, impotence of organic origin) is payable, but psychogenic impotence (302.72, psychosexual dysfunction; with inhibited sexual excitement) usually isn't at least not for a urologist.
 
Unless the urologist can document that the impotence is organic, the coder is stuck with 302.72, which is frequently not paid, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer based in North Augusta, S.C. "You may just have the patient telling you it doesn't work," Callaway says. But the urologist can't code 607.84 just to be paid. "The physician has to be confident that the impotence has an organic origin before coding 607.84."
 
The diagnosis coding dilemma for impotence is a typical one, according to  Callaway. "The coding world and the reimbursement world don't always agree," she says. "It shouldn't make a difference if you use a mental-health code." If the urologist determines the problem is psychogenic, 302.72 is the correct code. But billing that code means you won't be paid. "The minute you use a code from the psych section, your whole reimbursement scenario changes," she says.
 
Urologists should not use 302.72, because these cases probably belong in a psychiatrist's office. Payers see it the same way because most will not pay a urologist to treat a mental-health diagnosis.
 
"As soon as they see the mental-health diagnosis, the payer will automatically put it into mental-health benefits," says Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior consultant with Deloitte and Touche in Boston. "That means they won't pay a urologist." Medicare, when it pays 302.72, does so at a reduced rate.

Some Testing Is Covered

Even for organic impotence, Medicare will no longer pay for an extensive battery of diagnostic tests. The diagnosis will have to be based almost entirely on the history and physical, says Michael A. Ferragamo, MD, clinical assistant professor of Urology at the State University of New York, Stonybrook.
 
"They want you to do less testing, and instead diagnose from the history, physical exam and a few lab tests," Ferragamo says. The lab tests are mainly to rule out other problems such as diabetes.
 
Except for the impotence diagnosis itself, there are few diagnostic tests. Always payable are the urologist's history, exam and medical decision-making the main components of the E/M service. Medicare will pay for certain tests with a diagnosis of organic impotence; however, these tests are not designed to help diagnose the impotence, but rather to rule out other causes of the impotence.
 
For example, Medicare will cover a CBC (complete blood count), glucose and lipid profile (if they haven't been done within the past six months), thyroid tests, serum testosterone and prolactin in cases of low libido or testicular abnormality. If the patient has low testosterone or testicular abnormalities, you should order prolactin and LH (luteinizing hormone) tests as well, and if the prolactin is high, also order an endocrine workup
 
The urologist should conduct PSA (prostate-specific antigen) testing as well if the patient is a candidate for testosterone replacement.

Won't Be Paid

Many diagnostic tests for erectile dysfunction were payable in the recent past, but no longer are payable. These include 93980 (duplex scan of arterial inflow and venous outflow of penile vessels; complete study), 93981 (... follow-up or limited study), 54250 (nocturnal penile tumescence and/or rigidity test), 54231 (dynamic cavernosometry, including intracavernosal injection of vasoactive drugs [e.g., papaverine, phentolamine]), 54230 (injection procedure for corpora cavernosography), 74445 (corpora cavernosography, radiological supervision and interpretation), 36247 (selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family) and 95926 (short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs).
 
The above tests may still be payable under certain circumstances, such as if the patient has a lifetime history of erectile dysfunction, a history of perineal trauma, or no response to injection therapy. However, supporting documentation of such histories will be needed to get paid.

Not Medically Necessary

Certain tests have never been viewed as medically necessary by Medicare in cases of erectile dysfunction. These include 54240 (penile plethysmography), 93922 (non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral [e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement]), 93923 (non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study [e.g., segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia]) and other penile vascular studies, 93975 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study), 93976 (... limited study) and 93978 (duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study).

Outmoded Testing

Payers allow minimal actual testing because the results don't contribute much. "Most patients are able to discern whether they can obtain an erection and maintain it," notes the LMRP for erectile dysfunction from Trailblazers (M-1B.3). Many tests, the LMRP says, are redundant or outmoded and are not medically necessary.
 
Some carriers allow diagnosis codes linked to some evaluation procedures for erectile dysfunction, but not others. For example, Trailblazers allows 302.72, 302.79, 607.84 and 607.89 with 54200, 54230 and 93980-93981 and sometimes 37788, 37790, 54231 and 54235. Trailblazers does not allow these codes with 54240 or 54250 because it doesn't feel the procedures are medically necessary to arrive at these diagnoses. 

Related to Previous Surgery

If the impotence is related to previous surgery, such as radical pelvic or penile surgery, the most likely cause is a combination of injury to penile nerves and penile vessels. Therefore diagnostic tests are unnecessary, Ferragamo says. However, the office visit is payable with the organic impotence diagnosis code, 607.84.
 
Regardless of  the kinds of tests performed or how the impotence is treated, the diagnosis code is the same: 607.84, Ferragamo says. The history and physical lead to the diagnosis, and a limited number of blood tests are covered to rule out other problems, hormonal abnormalities, and pituitary or thyroid disease.

Other Diagnosis Codes

It's possible that the impotence has an unspecified diagnosis code. ICD-9 guidelines indicate that 302.72 should be used in this case, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and reimbursement consultancy based in Denver. If you're not sure whether the impotence is organic or psychogenic, code 302.72, not 607.84, Page says.
 
Do not confuse the payer by indicating that the problem is infertility (606.x), Page adds. The office visit will probably not be covered. Many carriers say infertility is not covered at all because they don't view it as a medical problem. Infertility is not the same as impotence. 
 
Commercial payers are a little more lenient than Medicare in terms of allowed diagnostic procedures, Ferragamo says. You may want to conduct a "trial-and-error" filing to see what they will pay. Ferragamo prefers the trial-and-error method because it is more reliable than asking the carrier's representative on the telephone. You will at least get a response from the system. Some coders prefer to consult the carrier first.    

Check Your LMRP

Depending on the carrier, the covered codes may differ. Medicare will cover psychogenic impotence at times, but at a reduced rate, meaning the patient's copayment increases from 20 percent to 35 percent. Triple-S pays for 607.84 or 302.72. Trailblazers pays for 302.72, 302.79, 607.84 and 607.89. Virginia Medicare pays for 302.72 and 607.84. Noridian North Dakota, South Dakota, Colorado and Wyoming pays for 302.70, 302.72 and 607.84. Empire New York pays for 302.72 and 607.84.
 
Commercial payers rarely pay urologists for 302.72; they have mental-health provider panels for mental-health diagnoses.
 
It is rare that impotence has only a psychological cause, Ferragamo says. When faced with a choice, always bill the organic impotence diagnosis code.
 
The workup may show different kinds of etiology since problems with erections can be caused by nerve problems, a spinal column problem, a penile problem or problems related to the muscles, tissues, veins and arteries in the corpora cavernosa. Many conditions can cause erectile dysfunction, and the urologist can be reimbursed to evaluate almost all of them except, most of the time, psychological factors.

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