Member’s Tip: Testosterone Replacement Therapy Coding
Submitted by 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. 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, however, 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.
Generally, you will 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 (depending on the Medicare carrier’s requirements).
Remember: Code J3490 is to be used only when a distinct HCPCS Level II code for the drug being administered has not been released. Whenever J3490 is used, you must include the name of the drug and any pertinent information, such as dosage and route of administration. Medicare policy is based on 106 percent of the Wholesale Acquisition Cost (WAC), or invoice pricing if the WAC is not published. Be prepared to furnish copies of invoices upon request.
Dosage is the total number of pellets implanted. The manufacturer’s 11-digit NDC number is placed on line 19 of the CMS-1500 form.
Diagnosis codes most commonly used are 257.2 other testicular hypofunction, 257.8 other testicular dysfunction, or 257.9 unspecified testicular dysfunction.