Billing and Coding: Treatment of Males with Low Testosterone

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.