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Injection documentation

William Ivan Posted Wed 20th of August, 2014 15:59:13 PM

Can you clarify what type of documentation is needed in the patient chart for a testosterone shot? (IE, Amount given, Lot #, site, etc). Additionally, could you possibly point me to the documentation that details out the required documentation.

SuperCoder Answered Thu 21st of August, 2014 08:36:04 AM

Thanks for your question.

CPT code for testosterone injection is 96372. For HCPCS code the dosage, means amount given of testosterone (in mg) is required.
Some more info on testosterone treatment is as follows:
Before testosterone treatment is considered, levels of the hormone are measured. To determine medical necessity, Aetna for instance requires two total testosterone levels. They require two morning samples be drawn on different days between 8:00 a.m. and 10:00 a.m. Once therapy is initiated, testosterone levels should be evaluated after three to six months of treatment and appropriate dose adjustments should be made to maintain desired serum testosterone levels. As part of the patient’s monitoring program, a hematocrit should be checked prior to the start of therapy, at three to six months, and then annually. If the hematocrit is >54%, testosterone therapy should be stopped until the hematocrit returns to normal. Injections of testosterone are usually given every 7 – 10 days on an outpatient basis. Testosterone may also be administered orally, topically, or via implantable pellets depending on the patient’s condition and preference.
Studies were recently published citing that men over age 65 using testosterone had nearly double the risk of a heart attack and younger men with a history of heart disease nearly tripled their risk.
Typically the provider will bill for testosterone testing (CPT codes 84402, 84403), an evaluation and management service (99201-99215 with modifier -25), therapeutic injection (96372), and injectable testosterone (J1060, J1070, J1080, J3120, J3130, J3140, J3150). A common diagnosis code reported is ICD-9 257.2 (other testicular dysfunction), but that may vary if the provider is tailoring his diagnosis coding based on the payer’s medical necessity criteria. Consideration should be given to auditing the top billing providers of testosterone to determine if they meet medical necessity criteria and the patients are being monitored appropriately.

Hope this answers your query.

Thank you!

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