Urology Coding Alert

Tip: When You should separately code semen analysis

Vasectomies can be one of the most common surgical procedures your urologist performs. Don't let "common" lead to "comfortable" and possibly missing some components of the service. Remembering these four areas will help you capture all of the urologist's deserved reimbursement.

1. Check Whether a Payer Wants a Consult or Office Visit Coding

The first time the patient visits your office regarding vasectomy, the urologist will discuss the procedure with the patient (and possibly his wife or significant other). The urologist will fully examine the patient, explain all aspects of the surgery, and will answer whatever questions they might have.

Code it: Check with the involved payer before assigning a code for this initial visit. Some insurers require a consultation code (CPT^® 99241-99245, Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making...). Others will ask for the appropriate office visit code, depending on whether the patient is new or established (99201-99205 for new or 99212-99215 for established).

Your diagnosis code will also hinge on the patient's status. Use ICD-10 code Z30.2 (Encounter for sterilization) most of the time, and when instructed by a particular carrier use code Z30.09 (Encounter for other general counseling and advice on contraception) as your diagnosis.

Tip: Assign the diagnosis code based on whether the patient has decided to proceed with the surgery or whether he is uncertain. Code Z30.2 is appropriate for confirmed surgery; Z30.09 applies when he is unsure whether he wants to have the vasectomy when he comes for his preoperative visit.

2. Watch for Open or Laparoscopic Approach

When reporting the actual vasectomy procedure, you have two possible options:

• 55250 – Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
• 55559 – Unlisted laparoscopy procedure, spermatic cord.

Take note: You lost an open procedure option in 2018, when previous code 55450 (Ligation [percutaneous] of vas deferens, unilateral or bilateral [separate procedure]) was deleted from CPT®. Use code 55250 for any open vasectomy, standard or non-scalp and code 55559 when the urologist performs the surgery laparoscopically.

For either type of approach, submit diagnosis Z30.2.

3. Report the Surgical Tray

When finalizing the claim, don't forget to report the surgical tray and supplies.

Remember: Medicare never pays for surgical trays, says Michael Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York. Include the tray on your claim, however, for documentation purposes and for any secondary payer.

Code it: Submit HCPCS code A4550 (Surgical trays) or CPT^® code 99070 (Supplies and materials [except spectacles], provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) for private or commercial carriers, a few of which may reimburse for a surgical tray/supplies.

4. The Final Step: Semen Analysis

The last step associated with a vasectomy is a series of follow-up tests to verify the eventual absence of sperm. Your urologist must examine the patient's semen to make this determination.

Work associated with these follow-up exams are included in the surgical code. Always document the service, but do not file a claim for them.

For an independent outside laboratory: The laboratory evaluation of the patient's samples is billable. If your office lab does not have CLIA certification that allows you to perform the analyses, the semen samples must be sent to an outside laboratory. The lab will bill the patient separately for these tests.