How To Use CPT Code 84410

CPT 84410 describes the measurement of bioavailable testosterone, which is the active form of testosterone that is loosely bound to albumin or exists as free, unbound hormone in the blood. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 84410?

CPT 84410 can be used to measure the bioavailable testosterone in a patient’s blood. Bioavailable testosterone refers to the active form of testosterone that is not bound to sex hormone binding globulin (SHBG) and is available for use by the body. This code is used when the lab analyst performs the necessary steps to process the patient’s serum and quantify the non-SHBG fraction of testosterone.

2. Official Description

The official description of CPT code 84410 is: ‘Testosterone; bioavailable, direct measurement (eg, differential precipitation).’ This code should not be reported in conjunction with codes 84402 and 84403, which are used for anabolic steroid testing for testosterone.

3. Procedure

1. The lab analyst receives the patient’s serum sample for testing.
2. The lab analyst performs the necessary steps to process the specimen, typically using a method called differential precipitation.
3. The lab analyst quantifies the bioavailable fraction of testosterone by precipitating the SHBG and measuring the remaining non-SHBG fraction.
4. The results are reported to the healthcare provider for further interpretation and management of the patient’s testosterone levels.

4. Qualifying circumstances

CPT 84410 is typically ordered by clinicians to monitor testosterone therapy or evaluate patients for conditions related to high or low levels of testosterone. It may be ordered for both male and female patients. Conditions associated with abnormal bioavailable testosterone levels may include low sex drive, infertility, premature or delayed puberty, certain tumors in men, menstrual cycle irregularities, ovarian cysts, and abnormal physical traits such as hirsutism in women. The adrenal glands and luteinizing hormone (LH) play important roles in testosterone production and regulation.

5. When to use CPT code 84410

CPT code 84410 should be used when there is a clinical need to measure the bioavailable fraction of testosterone in a patient’s blood. It is important to select the appropriate code from the testosterone family based on the specific fraction being measured (free, total, or bioavailable). Clinicians may order a combination of these tests, such as total and free, or total and bioavailable, depending on the clinical scenario.

6. Documentation requirements

To support a claim for CPT 84410, the healthcare provider must document the following information:

• Reason for ordering the test, including symptoms or conditions being evaluated
• Date of the test
• Results of the test, including the measured bioavailable testosterone level
• Interpretation of the results and any recommended management or treatment
• Signature of the healthcare provider ordering the test

7. Billing guidelines

When billing for CPT 84410, ensure that the test is performed to measure the bioavailable fraction of testosterone. It is important to use the correct code from the testosterone family based on the specific fraction being measured. If specimen collection is separately performed, it may be reported with a code such as 36415. It is also important to follow any specific guidelines or requirements from the payer regarding the reporting of testosterone testing.

8. Historical information

CPT 84410 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates to the code since its addition.

9. Examples

1. A clinician orders CPT 84410 to monitor the bioavailable testosterone levels of a male patient undergoing testosterone replacement therapy.
2. A clinician orders CPT 84410 to evaluate a female patient with hirsutism and irregular menstrual cycles for possible hormonal imbalances.
3. A clinician orders CPT 84410 to assess the testosterone levels of a male patient with delayed puberty.
4. A clinician orders CPT 84410 to investigate the cause of infertility in a couple, including evaluating the male partner’s testosterone levels.
5. A clinician orders CPT 84410 to monitor the testosterone levels of a female patient with polycystic ovary syndrome (PCOS).
6. A clinician orders CPT 84410 to evaluate a male patient with suspected testicular tumors for abnormal testosterone levels.
7. A clinician orders CPT 84410 to assess the testosterone levels of a female patient with amenorrhea and signs of virilization.
8. A clinician orders CPT 84410 to monitor the bioavailable testosterone levels of a transgender individual undergoing hormone therapy.
9. A clinician orders CPT 84410 to evaluate a male patient with symptoms of low libido and fatigue for possible testosterone deficiency.
10. A clinician orders CPT 84410 to assess the testosterone levels of a female patient with suspected adrenal gland dysfunction.