A study published in the Journal of Clinical Endocrinology & Metabolism at the beginning of this year points out that an increasing number of older and middle-aged men in the United States are being tested for low testosterone levels and being prescribed testosterone medications over the past decade. On the basis of this study, we can say there should be a hike in the number of patients visiting the physician’s office for testosterone shot. Practices should remain very cautious while billing for testosterone shot to receive maximum reimbursement in such a scenario. Appropriate diagnostic codes and procedural codes must be used for the services provided.
Though the common diagnostic code reported is ICD-9 257.2 (other testicular dysfunction), healthcare providers should tailor their diagnostic coding according to the payer’s medical necessity criteria, which we will see later. Typically, providers bill for the following services when patients visit a physician’s office or hospital setting for testosterone shot.
Testosterone Testing
Testosterone test measures the amount of testosterone in the blood. This test involves two types, one that measures the total amount of testosterone and another that measures ‘free’ testosterone. Two CPT codes are used for each type such as:
- 84402: Testosterone, free
- 84403: Testosterone, total
If a testosterone test measures total amount of testosterone and free testosterone, both CPT codes should be used for billing that service. For example, you should use only 84402 for ‘Testosterone, Free (Direct), Serum.’ But, for ‘Testosterone, Free (Direct), Serum With Total Testosterone,’ you should use both 84402 and 84403.
Therapeutic Injection
CPT code used for testosterone injection is given below with its description.
- 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
It is inappropriate to report this injection administration code without direct physician or other qualified healthcare professional supervision, unless the injection is administered in a hospital setting.
Injectable Testosterone
Here are the HCPCS codes used for specifying injectable testosterone during a visit.
- J1060: Injection, testosterone cypionate and estradiol cypionate, up to 1 ml
- J1070: Injection, testosterone cypionate, up to 100 mg
- J1080: Injection, testosterone cypionate, 1 cc, 200 mg
- J3120: Injection, testosterone enanthate, up to 100 mg
- J3130: Injection, testosterone enanthate, up to 200 mg
- J3140: Injection, testosterone suspension, up to 50 mg
- J3150: Injection, testosterone propionate, up to 100 mg
Evaluation and Management (E/M) codes
The following E/M codes are typically used to report evaluation and management services.
- 99201: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.
- 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.
- 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.
- 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.
- 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.
- 99211: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.
- 99212: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of 3 key components. Usually the presenting problem(s) are self-limited or minor
- 99213: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.
- 99214: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.
- 99215: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.
With the 2014 OPPS Final Rule, the Centers for Medicare & Medicaid Services (CMS) collapsed E/M codes for clinic visit Ambulatory Payment Classifications (APCs) so that the following codes are replaced with HCPCS code G0463 for 2014 and is assigned to APC 0634.
- 99201-99205 (new patient visit)
- 99211-99215 (established patient visit)
Though CMS finalized the rule that requires to bill G0463 for a hospital-based clinic visit, the payment change is applied only to the hospital technical component of clinic visits, not for the physician professional component payment. Physicians can continue to bill their level according to the CMS documentation guidelines for E/M assignment while ancillary services will continue to be paid separately in most situations.
Medical Necessity
As per the study mentioned at the beginning of this article, a large percentage of men initiate testosterone therapy without clear indication for treatment. In the opinion of researchers, medical necessity for testosterone treatment should be considered very closely before the initiation owing to the limited evidence of efficacy and unresolved safety concerns. In addition to this, many insurers insist on documentation supporting medical necessity of the therapy when submitting medical claims. In order to establish medical necessity, at least two total testosterone levels are needed. It is required to take two morning samples on different days between 8:00 a.m. and 10:00 a.m. Once the therapy starts, it is required to test testosterone levels after three to six months of treatment and make appropriate dose adjustments to maintain preferred serum testosterone levels. Hematocrit (HCT) needs to be checked before starting the therapy, at three to six months, and then every twelve months as a part of patient’s monitoring plan. If the hematocrit is less than 54%, testosterone therapy should be stopped till the hematocrit returns to normal level. CPT code 85014 is used to bill for hematocrit testing. All details regarding these tests should be documented for proving medical necessity.
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