Urology Coding Alert

Don't give up on sperm aspiration payment despite Medicare's policies

Male infertility is a common problem that urologists evaluate, and one procedure that physicians often use in their evaluation is sperm aspiration. Your challenge is figuring out how to report the procedure even though CPT Codes doesn't offer you a specific code. Take a look at these experts tips on how to properly code sperm aspiration procedures.

Get to Know the Aspiration Codes

When your urologist is using sperm aspiration to evaluate male infertility, he has three aspiration procedures to choose from:

• microsurgical epididymal sperm aspiration (MESA)

• testicular sperm aspiration (TESA, sometimes called TESE for testicular sperm extraction)

• percutaneous epididymal sperm aspiration (PESA).

There is no Category I procedure code for these procedures. For MESA, however, CPT offers an S code: S4028 (Microsurgical epididymal sperm aspiration).

Bad news: Not all payers, including Medicare, will pay for S4028. S codes, found only in the HCPCS manual, are temporary national codes for which Medicare will not reimburse you. You may typically report S codes to some private payers and Medicaid, but double-check the rules for your particular state and payer.

For payers that do not recognize S codes, you'll use the unlisted-procedure code, 55899 (Unlisted procedure, male genital system), for MESA. You'll also use the unlisted-procedure code for all payers when you're reporting TESA and PESA, says Kelly Young, a coder with Scottsdale Center for Urology in Scottsdale, Ariz.

Capture Pay for Other Procedures, Too

The three procedures above are not your only coding challenges for sperm aspiration. Take a look at these other coding options you may come across.

Option 1: If your urologist performs the sperm aspiration via fine needle aspiration with or without guidance, you should report that service. If the physician does not use image guidance, report 10021 (Fine needle aspiration; without imaging guidance), and if he does use guidance, report 10022 (Fine needle aspiration; with imaging guidance).

Bonus: When the urologist uses image guidance, be sure you also report a code for the type of guidance he provides, as follows:

• Use 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) when he uses sonography.

• Use 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) for fluoroscopy.

• Use 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation) when the urologist uses CT.

• Use 77021 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device], radiological supervision and interpretation) for magnetic resonance imaging (MRI).

Option 2: If the urologist performs a microscopic evaluation of the aspirates to determine the adequacy of the specimens before he submits them for final analysis, report 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) or 88173 (... interpretation and report).

Charge the Patient When Payers Deny

Many commercial and private insurance carriers often will not pay for male infertility diagnostic procedures or treatments, including MESA, PESA and TESA. For example, "We would never bill this to Medicare because it is not a 'medically necessary' procedure and Medicare would not cover it," Young says.

You should therefore check with the patient's insurance before the urologist performs the infertility service, and request and obtain precertification from the payer before the procedure. You should also obtain a signed advance beneficiary notice from the patient if you expect the carrier to deny payment.

"The majority of insurance companies will pay for the office visits for infertility but will not pay for any 'male' procedures for the treatment of or anything with diagnosis of azoospermia or infertility," says Chandra L. Hines, business office manager for NC Urological Associates Inc. in Raleigh, N.C. There are even some insurance companies that will not pay for any office visits for infertility, or reimburse for any treatments with a diagnosis of azoospermia, oligospermia or infertility.

Remember: ABNs help patients decide whether they want to proceed with a service even though they might have to pay for it. A signed ABN helps ensure that your office will receive payment directly from the patient if a carrier refuses to pay. Without a valid ABN, you cannot hold a patient responsible for the denied charges.

Good practice: Many urology practices require preoperative payment for MESA, TESA and PESA procedures. "It is always easier to collect the money prior to providing the service than after the patient has left your office," Young says.

"Even the patients with infertility benefits are charged as self-pay patients in our office because infertility benefits usually have a monetary cap, and this money is usually spent on the female portion of infertility treatments, which are a lot more expensive than the male portion," she adds.