Cut through the confusion around testosterone therapy CPT codes now.
Do you have low testosterone symptoms but feel confused about testosterone replacement therapy codes and insurance coverage? As a medical clinic specializing in properly managed testosterone therapy, we understand your concerns.
In this complete Q&A, we’ll clarify the specific CPT codes used for testosterone pellets, injections, counseling, and labs.
What is the CPT Code for Testosterone Replacement Therapy?
There is no single CPT code for testosterone replacement therapy. However, codes like 11980 for pellet implantation, J3121 and J1071 for injections, and 96372 for therapeutic injections cover the key components of TRT.
For the implantation of testosterone pellets, the appropriate CPT code is:
- 11980 – This covers subcutaneous insertion of the testosterone pellets, including making the necessary incision and then closing it afterwards.
Testosterone pellets provide sustained hormone release over a period of typically 3-6 months. About the size of a grain of rice, the pellets are placed under the skin using a device to avoid stitches. Code 11980 specifically covers the procedural service of implanting the pellets.
Injection Codes for Testosterone Cypionate and Enanthate
When it comes to testosterone injections, there are two main CPT codes we use:
- J3121 – Injection of testosterone enanthate, 1 mg
- J1071 – Injection of testosterone cypionate, 1 mg
These codes are billed based on the dosage administered. For example, a 200 mg injection would be billed as 200 units of the applicable code.
Other Important TRT-Related Codes
In addition to those above, a few other codes play an important role in testosterone replacement therapy:
- 96372 – Can be used for any therapeutic injection like testosterone
- 85014 – Covers hematocrit lab testing needed to monitor TRT
- S0189 – For billing testosterone pellets to private insurance (per 75 mg pellet)
- J3490 – For billing testosterone pellets for Medicare claims (as unclassified drug)
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What is the CPT Code for a Testosterone Test?
The main CPT codes for testosterone lab testing are 84403 for total testosterone, 84402 for free testosterone, and 84410 for bioavailable testosterone. Code 96372 is used for testosterone injections.
Based on our clinical experience, the most common CPT code our providers use for testosterone blood testing is 84403 for a total testosterone level. This measures the total amount of testosterone circulating in the blood, including both free and bound forms.
For additional details, we frequently also order code 84402, which specifically measures free or unbound testosterone. This shows the amount readily available for tissues to use.
Less common but also informative is code 84410 for bioavailable testosterone testing. This directly quantifies the testosterone that is available to the body’s tissues.
Finally, for testosterone injections we use CPT code 96372. This covers therapeutic injections administered subcutaneously or intramuscularly, as is typical for testosterone cypionate or enanthate.
What’s the CPT Code for Counseling in Testosterone Replacement Therapy?
There is no single CPT code just for counseling in testosterone replacement therapy. However, counseling is a typical part of the evaluation and management visit when initiating or monitoring TRT. For billing purposes, we would use the appropriate E/M code for the complete visit:
- 99202-99205 for a new patient
- 99211-99215 for an established patient
The specific E/M code depends on the complexity of the case and the total time spent face-to-face advising the patient. We make sure to document the counseling provided in the medical record, along with the total time spent with the patient.
Relevant ICD-10 diagnosis codes we would use include E34.9 for endocrine disorders and Z79.890 for hormone replacement therapy.
While not its own CPT code, counseling remains an important part of properly administering and monitoring testosterone replacement therapy for our patients.
Is Testosterone Replacement Therapy Covered by Insurance?
Insurance covers testosterone replacement therapy for hypogonadism and gender-affirming treatment, but coverage is controversial for off-label use in older men due to safety concerns.
TRT Covered for Hypogonadism and Gender-Affirming Use
- Most major insurance plans cover TRT when medically necessary for diagnosed conditions like hypogonadism causing abnormally low testosterone in men.
- Coverage also typically includes TRT for gender-affirming hormone therapy in transgender patients when specific clinical criteria are met.
- For these uses, insurance will often cover the full costs or require copays after approval. Medicare also provides coverage for appropriate candidates.
Off-Label TRT for Older Men More Controversial
- However, insurance coverage tends to be more restricted and controversial when TRT is prescribed off-label to aging men for age-related testosterone decline.
- Some studies have suggested potential increased health risks like cardiovascular effects with TRT in older men.
- Guidelines generally advise physicians to be selective in prescribing TRT to older men, mainly for sexual dysfunction after other causes are ruled out.
- The FDA has not approved TRT to combat nonspecific symptoms or general effects of aging in men.
Is Testosterone Replacement Therapy FDA Approved?
The FDA approves testosterone replacement therapy only for men with diagnosed hypogonadism causing abnormally low testosterone levels, not for age-related testosterone decline.
Approved Uses of TRT
The FDA has approved TRT for men who have hypogonadism – clinically low testosterone due to underlying health conditions such as:
- Genetic disorders impacting testosterone production
- Pituitary gland tumors or injury
- Chemotherapy or radiation treatment
- Testicular failure due to injury, infection, or other causes
These types of primary hypogonadism lead to very low natural testosterone levels, which TRT can effectively and safely treat when properly monitored by a physician.
No Approval for Age-Related Low Testosterone
However, the FDA has not approved the use of TRT to treat low testosterone related to aging, even if men have symptoms of fatigue, low libido, erectile dysfunction, and loss of muscle mass.
This age-related decline in testosterone is sometimes referred to as “andropause” but it is not an approved use of TRT according to the FDA.
Ongoing Safety Monitoring of TRT
The FDA does require boxed warnings about potential cardiovascular side effects like blood clots, heart attack, and stroke for prescription testosterone products. Careful medical oversight and periodic lab testing are crucial for minimizing risks when using TRT.
While TRT has demonstrated benefits like increased energy, libido, and muscle mass in hypogonadal men, some concerns remain about long-term safety, especially prostate effects, based on the lack of large, multi-year studies.
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