Urology Coding Alert

Hint: Remember to include J3490 or S0189 on your claim.

If your urologist performs in-office placement of estradiol/testosterone pellets, remember to include the appropriate drug code along with the procedure code on your claim. You should also double-check which diagnosis code supports the medical necessity of the implantation code.

Don’t miss: Estradiol pellets, with or without the addition of testosterone, may be used to help control menopausal symptoms in women. Testosterone pellets are used for growth retardation in young males, a low testosterone level, aging changes, and loss of sex drive in older males.

Follow these handy tips to submit clean testosterone and estradiol pellet insertion claims in your urology office.

Tip 1: Rely on 11980 for Pellet Insertion

When your urologist implants testosterone/estradiol pellets, he will make a subcutaneous incision with a trocar needle. He will use forceps to create a space, and he will push the hormone pellets inside these spaces. The hormones are then converted to pellets such as testosterone and estradiol, which have sustained or controlled release properties.

You should report code 11980 (Subcutaneous hormone pellet implantation [implantation of estradiol and/or testosterone pellets beneath the skin]) for a subcutaneous hormone pellet insertion procedure.

Tip 2: Include Appropriate Drug Supply Code

When you report hormone pellet implantation, don’t forget to report the appropriate code for the drug supply.

Medicare: For Medicare and Medicare replacement plans, and some private plans, you should report J3490 (Unclassified drugs).

Private payers: For some private payers, you should report S0189 (Testosterone pellet, 75mg). 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.

Your urologist will usually implant between six and 30 pellets per procedure, according to Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. However, some Medicare contractors and private payers place limits on the number of pellets they reimburse. For example, according to the Centers for Medicare & Medicaid Services (CMS), Medicare may only cover the number of pellets actually implanted in the patient (maximum of six pellets). Wastage is not covered, but you may be able to get paid for additional pellets on appeal if your documentation supports medical necessity determined by the Food and Drug Administration (FDA) drug level and if the service meets Medicare’s requirements.

If your urologist implants more than six pellets, you must explain to your carrier what testosterone blood levels you wish to achieve and how many pellets were necessary to reach that level, Ferragamo says.

Don’t miss: Different payers may have different policies for pellet insertion, so you should always check with your particular payer.

For example, Aetna considers implantable estradiol pellets “experimental and investigational because they have been shown to produce unpredictable and fluctuating serum concentrations of estrogen.”

On the other hand, Aetna considers implantable testosterone propionate implant pellets medically necessary for certain conditions including delayed male puberty and gender dysphoria in a patient who is able to make an informed decision to engage in hormone therapy.

Additionally, primary or hypogonadotropic hypogonadism is covered when the following criteria are met:

• Before the start of testosterone therapy, the patient has at least two confirmed low morning testosterone levels according to current practice guidelines or standard lab reference values; or
• For continuation of testosterone therapy, before the patient started testosterone therapy, they had a confirmed low morning testosterone level according to current practice guidelines or standard lab reference values.

Aetna considers implantable testosterone pellets experimental and investigational for conditions not mentioned above.

Read more about Aetna’s pellet insertion policy here: http:// www.aetna.com/cpb/medical/data/300_399/0345.html.

Tip 3: Choose Correct ICD-10-CM Code

When you report estradiol/testosterone pellet insertion, you must also include the correct ICD-10-CM code on your claim. Some examples of supporting ICD-10-CM codes include the following:

• E23.0 (Hypopituitarism)
• E29.1 (Testicular hypofunction)
• E29.8 (Other testicular dysfunction)
• E29.9 (Testicular dysfunction, unspecified)
• E30.0 (Delayed puberty)
• E89.5 (Postprocedural testicular hypofunction)
• F64.0 (Transsexualism)
• F64.1 (Dual role transvestism)
• F64.8 (Other gender identity disorders)
• F64.9 (Gender identity disorder, unspecified)
• Z87.890 (Personal history of sex reassignment)

Remember: Different payers may have supporting ICD-10-CM codes they will accept, so you should always double-check with them.

Tip 4: Don’t Forget Additional Procedures

In some cases, your urologist may place sutures at the implantation site for patients with bleeding tendencies or for patients who are on Coumadin or low-dose aspirin therapy. You should report those services in conjunction with code 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).

Don’t miss: A procedure-to-procedure (PTP) National Correct Coding Initiative (NCCI) edit exists between 12001 and 11980. Code 12001 is a Column 2 code for 11980, meaning those two codes are bundled. However, you can use a NCCI-associate modifier to override this edit under the appropriate circumstances.