LCD Reference Article Billing and Coding Article

Billing and Coding: Treatment of Males with Low Testosterone

A58828

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A58828
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Treatment of Males with Low Testosterone
Article Type
Billing and Coding
Original Effective Date
02/13/2022
Revision Effective Date
02/13/2022
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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

Title XVIII of the Social Security Act §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50.4.3 Examples of Not Reasonable and Necessary #2. Injection Method Not Indicated and §80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Treatment of Males with Low Testosterone L39086.

The Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to NCCI edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and National Provider Identifier (NPI) of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under §1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Coding Guidance: Providers should refer to the applicable American Medical Association (AMA) CPT® Manual to assist with proper reporting of these services.

Injectable testosterone pellets (brand name Testopel®) may be covered, by Medicare, for the United States (U.S.) Food and Drug Administration (FDA) approved indication, if the service meets all Medicare coverage requirements quoted in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50.4.3 Examples of Not Reasonable and Necessary #2. Injection Method Not Indicated.

Pellet implantation is much less flexible for dosage adjustment and more invasive than oral medication, nasal administration, transdermal administration or intramuscular injection. This A/B MAC believes 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.

The number of pellets to be implanted depends upon the minimal daily requirements of testosterone propionate titrated to a serum testosterone level in the low normal range for a healthy adult male. The usual dosage is 150 mg to 450 mg subcutaneously every 3 to 6 months, which translates to 2 to 6 pellets every 3 to 6 months. Insertion of more than 6 pellets every 3 months will not be considered reasonable and necessary. Medicare may only cover the number of pellets actually implanted in the patient (maximum of 6 pellets); wastage is not covered.

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (see Coverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Medical record documentation must be available to Medicare upon request.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(7 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE SKIN)
84410 TESTOSTERONE; BIOAVAILABLE, DIRECT MEASUREMENT (EG, DIFFERENTIAL PRECIPITATION)
96372 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR
J1071 INJECTION, TESTOSTERONE CYPIONATE, 1 MG
J3121 INJECTION, TESTOSTERONE ENANTHATE, 1 MG
J3145 INJECTION, TESTOSTERONE UNDECANOATE, 1 MG
J3490 UNCLASSIFIED DRUGS
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(38 Codes)
Group 1 Paragraph

The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the determination.

Group 1 Codes
Code Description
D35.2 Benign neoplasm of pituitary gland
D44.3 Neoplasm of uncertain behavior of pituitary gland
E23.0 Hypopituitarism
E23.1 Drug-induced hypopituitarism
E23.3 Hypothalamic dysfunction, not elsewhere classified
E23.6 Other disorders of pituitary gland
E23.7 Disorder of pituitary gland, unspecified
E29.1 Testicular hypofunction
E29.8 Other testicular dysfunction
E30.0 Delayed puberty
E89.5 Postprocedural testicular hypofunction
F64.0 Transsexualism
F64.1 Dual role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
N44.00 Torsion of testis, unspecified
N44.01 Extravaginal torsion of spermatic cord
N44.02 Intravaginal torsion of spermatic cord
N44.03 Torsion of appendix testis
N44.04 Torsion of appendix epididymis
N45.2 Orchitis
N50.89 Other specified disorders of the male genital organs
Q53.00 Ectopic testis, unspecified
Q53.01 Ectopic testis, unilateral
Q53.02 Ectopic testes, bilateral
Q53.10 Unspecified undescended testicle, unilateral
Q53.111 Unilateral intraabdominal testis
Q53.112 Unilateral inguinal testis
Q53.12 Ectopic perineal testis, unilateral
Q53.20 Undescended testicle, unspecified, bilateral
Q53.211 Bilateral intraabdominal testes
Q53.212 Bilateral inguinal testes
Q53.22 Ectopic perineal testis, bilateral
Q53.9 Undescended testicle, unspecified
Q55.0 Absence and aplasia of testis
Z87.890 Personal history of sex reassignment
Z90.79 Acquired absence of other genital organ(s)
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description
N/A

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.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
02/13/2022 R1

Under CPT/HCPCS Codes Group 1: Codes deleted S0189.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39086 - Treatment of Males with Low Testosterone
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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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
01/20/2022 02/13/2022 - N/A Currently in Effect You are here
12/20/2021 02/13/2022 - N/A Superseded View

Keywords

  • Testosterone Treatment
  • Testosterone