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.

Urology – CUC

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.

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7 Responses to “Member’s Tip: Testosterone Replacement Therapy Coding”

  1. Carolyn Wright says:

    I need an injection code for the testosterone shot. Our patient’s buy the medicine, and then we give them their shot. I use the code 99211, but most of our patient’s insurance company uses this as their co-pay, and alot of our patients cannot afford this on a weekly basis. Thank you very much.

  2. N. Martin, CCS, RMM says:

    You would use 96372, therapeutic injection. 99211 is incorrect; however, the patient’s insurance company should not apply a copay to the 99211 code. This code is for a non-physician service.

  3. Nancy Panzica says:

    I have been using 99211 as the 96372 has been being rejected by the ins. companies as “incidental to the E/M services”….well, if they want it incidental to the services, I have to bill them for a service then, right? I do know that Vitamin B12 should be billed with the 99211 not the 96382 per CMS, so I find this a similar correlation. The allowed amount is usually less than the patient’s copay ($25.15 in my locality for this insured patient). Patient was upset anyway–he thought he should get the injection for free.

  4. Lise Armour says:

    Hi All,
    If the the below statement is true, then wouldn’t it stand to reason that HCPCS code S0189 is a HCPCS code so we could not then use the J code? Even if it is for BC/BS only.

    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.

  5. Susan Gochoco says:

    My Urologist wants to bill for the repair of the insertion site with cpt 12001. He states that steri strips are typically included in cpt 11980, but he plans to use a single suture, so he wants to bill 12001. I thought this part of the procedure would be considered part of the global surgical package, but he does not agree. Thoughts please ?

  6. Joe Sunshine says:

    I agree, should be included. Any other comments?

  7. Kyle says:

    I’m using 96372 with J1080 and the dx code 257.9. I’m not sure if this is correct because I heard from different people that they are using different code. I work for Internal Medicine. So if this is not correct please let me know. Your comments would be appricated.

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