Local Coverage Article Billing and Coding

Billing and Coding: Testopel Coverage

A55057

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Contractor Information

Article Information

General Information

Article ID
A55057
Article Title
Billing and Coding: Testopel Coverage
Article Type
Billing and Coding
Original Effective Date
07/12/2016
Revision Effective Date
07/12/2016
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text
Injectable testosterone pellets (brand name Testopelâ„¢) may be covered, by Medicare, for the FDA approved indication, if the service meets all Medicare coverage requirements quoted below verbatim in the Internet Only Manual (IOM) Medicare Benefit Policy Manual (MBPM) Chapter 15, Section 50.4.3.2 MBPM

Injection Method Not Indicated

Medication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. For example, the accepted standard of medical practice for the treatment of certain diseases is to initiate therapy with parenteral penicillin and to complete therapy with oral penicillin. Carriers exclude the entire charge for penicillin injections given after the initiation of therapy if oral penicillin is indicated unless there are special medical circumstances that justify additional injections."

The Noridian Contractor Medical Directors (CMDs) believe that the use of this product should be rare since the "accepted method of medical practice" is to administer testosterone transdermally, but there may be reasons that require this injectable medication. Compliance with Medicare requirements is subject to review by the Recovery Auditors.

A submitted claim form must contain the below information.

  • In Item 19 of CMS-1500 paper claim form or Loop 2400/SV101-7 for electronic claims

  • Enter word "Testopel"

  • Enter drug dosage given (include milligrams delivered only)

  • NOTE: Medicare may only cover the number of pellets actually implanted in the patient (maximum of six pellets); wastage is not covered. Use of additional pellets may be paid on appeal if the documentation supports medical necessity as determined by the FDA approved drug label and the service complies with all Medicare requirements as indicated above.

  • Item 24D or electronic equivalent

  • Enter J3490


Coding Information

CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
999x Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
07/12/2016 R4

Converted to Billing and Coding article type only. No changes to article content.

07/12/2016 R3 R3 Under submitted claim form information; Change to: Enter drug dosage given (include milligrams delivered only) and add: In Item 19 of CMS-1500 paper claim form or Loop 2400/SV101-7 for electronic claims.
07/12/2016 R2 Correction and addition to hyperlink referencing the Medicare Benefit Policy Manual
07/12/2016 R1 Revised the link to the IOM

Associated Documents

Related Local Coverage Documents
LCDs
L36569 - Treatment of Males with Low Testosterone
Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
05/08/2020 07/12/2016 - N/A Currently in Effect You are here
12/08/2016 07/12/2016 - N/A Superseded View
05/12/2016 07/12/2016 - N/A Superseded View
05/12/2016 07/12/2016 - N/A Superseded View
05/10/2016 07/12/2016 - N/A Superseded View

Keywords

  • Testopel
  • Coverage
  • Injection
  • Method
  • Testosterone
  • Pellets