TrailBlazer: Testopel Non-covered
If you commonly report CPT® 11980 Subcutaneous hormonal pellet implantation beneath the skin along with either HCPCS Level II code S0189 Testosterone pellet, 75 mg or J3490 Unclassified drug, you may want to check with your payer to make sure your claims will be paid.
TrailBlazer Health Enterprises, Medicare administrative contractor for jurisdiction 4 (J4-MAC), recently announced that, effective for dates of service on or after April 12, 2012; J3490/S0189, when used to bill for Testopel™ (testosterone pellet), will be non-covered as a self-administered drug. CPT® code 11980, when used to bill for the implant of this hormone pellet in conjunction with J3490/S0189, will be non-covered, as well.
The active ingredient of Testopel™ is testosterone. Testosterone is actively marketed as administered topically or orally for frequent use by the patient, according to Marlene Doty, CPC, CUC, PCS.
“A physician may offer a male patient diagnosed with low testosterone, or ‘Low T,’ varying options of medical treatment to relieve symptoms,” said Doty. “One of those options is testosterone replacement therapy, which consists of testosterone pellets inserted by subcutaneous implantation once every 3-6 months in the office.
“Before billing for this procedure,” Doty warns, “it is important to contact the specific insurance carrier for coverage determination and, if required, prior authorization.”
Low testosterone is the body’s inability to produce enough testosterone. Symptoms of low testosterone may include: loss of energy and moodiness, diminished sex drive, weight gain, and loss of muscle mass and bone strength.
Diagnosis codes most commonly used are 257.2 Other testicular hypofunction, 257.8 Other testicular dysfunction, or 257.9 Unspecified testicular dysfunction.