Urology Coding Alert

Get to know your payers’ policies or you may give away part of the service for free.

Many practices are facing revenue declines each year, and are looking at ways to bring in additional money by providing ancillary services. One such procedure that many urology practices are doing or are considering performing in-office is the placement of testosterone pellets for patients with testicular dysfunction. But getting paid correctly for those procedures can pose a challenge.

Read on to get the lowdown on coding for testosterone pellet implantation so your practice brings in every dollar you deserve if you start performing the procedures in your office.

Step 1: Start With the Implantation Code

During the implantation procedure, your urologist will use a trocar needle to insert estradiol and/or testosterone pellets into the subcutaneous layer of the patient’s skin, explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. For the actual subcutaneous hormone pellet insertion procedure, you should report 11980 (Subcutaneous hormone pellet implantation [implantation of estradiol and/or testosterone pellets beneath the skin]).

Money matters: Code 11980 carries 2.66 relative value units (RVUs) for a procedure your urologist performs in the office. When you multiply the RVUs by the $35.7547, the 2015 conversion factor, you can see the reimbursement based on the 2015 unadjusted Medicare physician fee schedule for the actual implantation is $95.11.

Step 2: Don’t Forget to Bill for the Pellets

Not only will you report 11980 for the implantation, but you should also report the supply code for the pellets your urologist implanted. How you bill and the reimbursement you can expect varies by payer, Ferragamo warns.

Medicare: For Medicare and Medicare replacement plans, and some private plans, you will report J3490 (Unclassified drugs). You should include the full price of the pellets in box 24 of the claim and add 1 unit in box 24G.

A urologist usually implants between six and 30 pellets per procedure, Ferragamo says. Some Medicare contractors and some private payers place limits on the number of pellets they will reimburse. For example, National Government Services (NGS) only pays for six pellets (450 mg) per treatment, according to their Website (http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/testosterone pellet dosage).

“Medicare may pay up to $100 per pellet,” Ferragamo says. One Medicare contractor, for example, was paying $73 per pellet. The cost per pellet from the manufacturer is around $73. “Therefore, before you start doing this procedure, determine your carrier’s reimbursement for the pellets, otherwise you may lose money when performing this procedure,” Ferragamo cautions.

Private payers: For some private payers, you will report S0189 (Testosterone pellet, 75mg). You should include the full price of the pellets in box 24 of the claim and the exact number of pellets used in box 24G. Some private payers also limit the number of pellets for which they will pay, so check with your payer to ensure you only bill for the allowable number.

“If you implant more than six pellets, you must explain to the carrier what testosterone blood levels you wish to achieve, and how many pellets are necessary to reach that level,” Ferragamo says. “If you indicate the lower blood level attained after six pellets and the need for additional pellets to obtain a higher therapeutic level, many carriers will allow and reimburse you for the extra pellets.”

Payment from private payers ranges from $77 to $112 per pellet, Ferragamo adds.

Note: Some payers, including some Medicare contractors, are requiring documentation for all testosterone implant procedures before paying and also are requiring evidence that other therapies have failed. Be sure you check your payer’s requirements to avoid unexpected denials.

Step 3: Assign the Right Diagnosis Code

The final piece of the coding puzzle is to choose the appropriate diagnosis code for your testosterone implantation claim. You will likely choose one of the following three codes:

• 257.2 — Other testicular hypofunction (which includes testicular hypogonadism and low testosterone levels)
• 257.8 — Other testicular dysfunction
• 257.9 — Unspecified testicular dysfunction.

Remember that medical necessity is going to be your key to successful reimbursement for these procedures, just like any other procedure your urologist performs.

Step 4: Check for Additional Procedure

Some urologists are placing a suture at the implantation site for patients with bleeding tendencies or for patients who are on Coumadin or low-dose aspirin therapy, Ferragamo says. “In some cases, practices are being paid for those sutures,” he says.

In those cases, you would report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) with diagnostic code 879.6 (Open wound of other and unspecified parts of trunk without complication). You’ll need to attach modifier 59 (Distinct procedural service) to 12001 since the Correct Coding Initiative (CCI) bundles the suture procedure into the implantation service.