Thursday, August 25, 2011

It’s a mans world… Coding for vasectomy

It’s a mans world… Coding for vasectomy

When looking at vasectomy codes in the CPT book, it seems like a very straightforward type of procedure. Upon closer review, a coder really has more choices that what is readily apparent.

A vasectomy is a permanent form of birth control or sterilization for a man, and can be performed in as little as 30-40 minutes. Vasectomy procedures are routinely performed in a variety of settings such as a physician office, outpatient clinic or even an ambulatory surgery setting. The majority of vasectomy procedures are performed in a physician office.

The most commonly performed vasectomy procedure is the traditional vasectomy designated by CPT code 55250. ICD9 Vol 3 procedure code lists this as 63.73. A newer approach for vasectomy is referred to as the ‘no-needle, no scalpel” and this procedure is primarily coded with CPT code 55450, ICD-9 Vol3. as 63.71. Physicians can also perform a laparoscopic vasectomy, although this is the least commonly performed vas procedure. A laparoscopic vasectomy is usually performed in conjunction with another procedure such as an inguinal hernia repair, therefore avoiding an additional incision for the vasectomy. CPT has not designated a specific code for a laparoscopic vasectomy, so it would be appropriate to use code 55559 unlisted procedure on spermatic cords, in addition to the primary laparoscopic code. ICD-9 Vol3 directs us to use 63.99 as other operations on the spermatic cord, epididymis, and vas deferens.

As a coder, it is important for you to understand what is involved with the procedure itself for successful code designation. Understanding and recognizing the surgical approach of the procedure detailed in the operative note is the critical piece of the coding puzzle.


“Traditional” Vasectomy
The “Traditional” vasectomy procedure code 55250 is an open-style procedure which involves a direct incision performed on the side of the scrotum, after an injection of anesthesia to the surrounding area or a nerve block injection is performed. The vas deferens is then pulled up and inspected visually. The physician will ether cauterize, cut, tie off, or occlude with clips or implants to the vas itself. The Vas deferens is then placed back into the srotum and the open incision is stitched or sealed with dermabond, in some cases the physican may only place a bit of surgi-tape or a butterfly-type bandage. The traditional vasectomy can be performed in the physicians office, or an outpatient clinic or ambulatory surgery center.

No Needle No Scalpel Vasectomy
In the case of a ‘no-needle no-scalpel’ procedure the procedure is very similar to the open procedure, however it is performed as a percutaneous entry into the scrotum. The no-needle portion of this is in reference to the anesthesia. The physician uses a directed high pressure jet injector system to deliver the anesthesia prior to the procedure. The no-scalpel portion refers to the instrumentation being used. These special instruments are similar to a small punch or puncture type procedure resulting in a ‘hole’ in the scrotum rather than the traditional ‘incision’. Again, the physician gently pulls the vas deferens out of the hole and ether cauterizes, cuts, ties or occludes the vas with clips or occlusive implants. This procedure can be performed in the physician office, or outpatient clinic or ambulatory surgery center.

Laparoscopic Vasectomy
The laparoscopic vasectomy is not normally performed by itself. It is usually performed in conjunction with another laparoscopic procedure performed on the same day. When this type of vasectomy is performed, CPT and ICD-9 Vol3 have not designated a specific procedure code for this. The laparoscopic vasectomy also severs the vas deferens, but again, it is the surgical approach that differentiates what code you should append. As a coder you should append the unlisted code(s) of 55559 or V63.99. As with any unlisted type procedure, be prepared to forward copies of the operative note and medical necessity documentation to support your claim for payment of an unlisted procedure to the 3rd party insurance carrier.

The Diagnosis Connection
As with any procedure the diagnosis is an integral part of the case. Diagnosis code V25.2 should be appended to the vasectomy sterilization procedure. However, if the procedure is being performed for a medical, or therapeutic reason, such as groin pain, the diagnosis should reflect that.

What else do you need to know?
Evaluation and Management or Sterilization Consultations performed by the physican on the same day as the procedure itself require usage of the modifier 25 to your insurance claim. Modifier 25 is necessary to support the documentation for a separately identifiable service. In addition, billing for surgical trays and local anesthesia supplies are commonly considered ‘bundled’ by most insurance payers with the vasectomy procedure itself.

Post operatively, a semen or sperm count will need to be performed before the patient can be deemed ‘sterile’. Normally 3 separate sperm counts will be performed post procedure over the course of 90 days. These tests are considered ‘bundled’ with the vasectomy procedure. It is inappropriate to bill these as a separately identifiable service to the patient or the insurance carrier.

Do not use modifier -50 if a vasectomy is performed as a bilateral procedure. CPT notes in the verbiage of the code descriptor code is applicable when performed as a unilateral or bilateral procedure. By the same rationale, do not use a modifier 52 if the procedure is only performed unilaterally or on one side only.

Insurance carriers have many differing policies in regard to payment for an elective vasectomy, when performed for sterilization. It is advisable to pre-authorize any vasectomy procedure with the insurance carrier. If the carrier does not provide coverage or payment for a vasectomy service, then payment should be collected directly from the patient. However, some 3rd party insurance policies do cover sterilization procedures, but if you cannot get a pre-authorization from the carrier, an advance beneficiary notice should also be obtained.


The operative reports:

Op Report – Tradtional Vasectomy
REOPERATIVE DIAGNOSIS: Voluntary sterility.
POSTOPERATIVE DIAGNOSIS: Voluntary sterility.
OPERATIVE PROCEDURE: Bilateral vasectomy. ANESTHESIA: Local.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the procedure table. Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin. A small incision was made in the right hemiscrotum. The vas deferens was grasped with a vas clamp. The vas deferens was skeletonized, clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum. The same procedure as above was performed on the left hemiscrotum without complication. A jockstrap and sterile dressing were applied at the end of the case. Sponge, needle, and instruments counts were correct.


Op Report No-Scalpel Vas

PREOPERATIVE DIAGNOSIS: Desire for sterility.
POSTOPERATIVE DIAGNOSIS: Desire for sterility.
OPERATIVE PROCEDURES: Vasectomy.

DESCRIPTION OF PROCEDURE: The patient was brought to the suite, where after oral sedation, the right and left scrotum prepped and draped. Then, 1% lidocaine was used for anesthesia though mada-jet. . The right vas was identified by palpation, scrotal skin was punctured with the no scalpel instrumentation device and used to dissect out the vas. A segment about 3 cm in length was dissected out. It was clipped proximally and distally, and then the ends were cauterized after excising the segment. Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic. The identical procedure was performed on the left side. Patient to recovery in good condition.

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