Male Infertility Surgical Procedures Coding

In male infertility surgical procedures, for sperm aspiration many use microsurgical technology— where a microscope is used to perform the procedures. For instance, we have a microsurgical epididymal sperm aspiration called the MESA; testicular sperm aspiration called TESA; and we also have a percutaneous epididymal sperm aspiration, the PESA. The last two procedures— the TESA and PESA— do not have a specific CPT procedural code, and are rarely covered by any insurance carrier. Before performing any of these three procedures, you should always verify coverage and obtain authorization from the carrier. Most often, these codes are not covered and are rather expensive, one may require negotiation with the patient and preoperative payment by the patient.

And certainly consider having the patient sign a waiver when you intend to do one of these procedures. Consider an Advanced Beneficiary Notice, an ABN. Although, MESA does have a HCPCS code that is S4028. HCPCS codes and S-codes are never reimbursed by Medicare. Medicare will never reimburse for an S-code. This, again, is the microsurgical epididymal sperm aspiration which will have payment – for which you can get payment for such diagnosis as congenital absence of the vas. This particular code will not result in payment if you are performing a microsurgical epididymal sperm aspiration following a vasectomy. You should negotiate fees with the carriers but the patient should remember that they are often financially responsible if especially if the carrier denies the coverage.

How should we code for sperm aspiration?

We have those three codes, the MESA, the TESA and the PESA. These patients will sometimes have coverage when coding using certain either unlisted or other CPT codes. You may be paid for these procedures using the following codes. Many physicians use the code 55899, an unlisted procedure for male genital system. You do have a HCPCS code for the MESA that you may want to use. Other physicians have used the fine needle aspiration with and without image guidance. Unfortunately, these codes pay very small, very little as compared to the technical work and knowledge required for doing the MESA, TESA or the PESA procedure.

With certain carriers such as Anthem, you must list the number of aspirations you do per line or the number of units in box 24G or the number of aspirations that you took in box 24G. Now, one may also consider using codes for needle biopsy of the testicle, 54500 and needle biopsy of the epididymis, 54800 for these testicular biopsies. However, many physicians feel that these latter codes pay significantly less than one would expect from these special aspiration procedures. And therefore, most physicians will bill and hold the patient financially responsible. Many times, the physician will ask for payment upfront, bill the carrier and repay the patient back if he is paid by the carrier, reimburse the patient if the carrier does pay.