Pathology/Lab Coding Alert

Question: What is the correct code for a postvasectomy semen exam? All we report is sperm present or absent. If sperm are present, we give a comment like rare, few, many, etc.

Nebraska Subscriber

Answer: CPT 2001 includes a new code for reporting this service. Code 89321 (semen analysis, presence and/or motility of sperm) describes the standard postvasectomy semen exam as you described it. Although this service was previously reported using 89300, that code is no longer appropriate. The post-vasectomy semen analysis is a more limited test that is usually performed 12 to 14 weeks after the procedure to confirm a successful surgery. It does not include the Huhner test, which is why 89300 is no longer appropriate.

Note that there is also a new ICD-9 code to report the reason for the patient encounter for the postvasectomy semen exam, V25.8 (other specified contraceptive management, postvasectomy sperm count). This code excludes sperm count following sterilization reversal or sperm count for fertility testing.


Answers to "You Be the Coder" and "Reader Questions" provided by William Dettwyler, MT-AMT, an independent pathology coding consultant based in Salem, Ore.