Vasectomy CPT Code

(2022) Vasectomy CPT Code 55250 – Description, Guidelines, Reimbursement, Modifiers & Examples

Vasectomy CPT Code 55250 describes the surgical procedure for male sterilisation, also called permanent contraception.

CPT code 55250 is also designated as ‘vasectomy’ and is intended for protection against pregnancy permanently. Vasectomy is a minor surgery to prevent pregnancy, and it is safer than any other birth control procedure.

Description Of Vasectomy CPT Code 55250

Vasectomy CPT code 55250 can be used to bill sterilisation (tubal ligation) for men. Sterilisation means permanent birth control to prevent pregnancy. Both men and women can be sterilised.

Description Of Vasectomy CPT Code 55250
Description Of Vasectomy CPT Code 55250

Vasectomy is a surgical procedure (CPT 55250) in which the provider cuts the tubes that carry sperm to prevent pregnancy. This procedure (CPT 55250) is specifically for male sterilization.

The term vasectomy originates from the name of tubes (vas deferens) in the scrotum that is blocked during the procedure.

Vasectomy (55250 CPT code) is a minor surgical procedure that blocks sperms from reaching the semen ejaculated from the penis. 

The production of sperms and sex hormones is carried out in the testicle that can fertilize a female egg, resulting in pregnancy. 

Sperm leaves the testes through a coiled tube called the epididymis. Both epididymis’ are associated with the ejaculatory by a long tube called vas deferens.

Vas deferens is a long tube-like structure that connects the seminal vesicle and thus making the duct called the ejaculatory duct.

Sperms are usually mixed with seminal fluid to produce semen if normal ejaculation is carried out. 

Semen flows through the urethra, comes out from the penis, and ejaculates with sperm to cause pregnancy.

Vasectomies are categorized into two types. One type of vasectomy is the incision method, and the other type is the no-scalpel (no cut) method.

The vasectomy CPT code 55250 procedure is usually performed in the provider’s office but may also be done at a surgical center or hospital.

The provider may decide if the patient needs to be fully sedated for the procedure (CPT 55250). If fully sedation is required, the vasectomy CPT 55250 code is performed at a surgical center or hospital.

While carrying out the vasectomy (CPT code 55250), the scrotal zone must be clean-shaven and washed away with an uncontaminated solution. The usage of local anesthesia for sedation of the scrotal area must be carried out, but a patient may feel touch, tension, and movement.

The provider can make a small incision at the scrotum coating to grasp the vas deferens. 

The provider cuts down the vas deferens and removes a small length of a piece to create a gap between both ends of vas deferens intentionally. The provider then ties the cut end with dissolvable stitches to close their own.

Post-operative procedure patients may have a small risk of bleeding into the scrotum. If patients observe scrotum swelling or scrotum pain, then patients need to consult with the provider.

Sometimes post-vasectomy pain occurs in patients. This may occur in 1 man out of 100 vasectomies.

Vasectomy CPT code 55250 as discussed above; the patient may discharge on the same day. Patients may need pain medication to reduce pain after surgery.

If severe pain persists, the patient may have an infection, so consultation with the provider is necessary. The patient may begin sexual activities again, within a week, after the vasectomy (55250 CPT code). Surgical vasectomy is an irreversible procedure. 

It is possible to have the vasectomy reversed only if a reversal is carried out within ten years, but the success rate is 55%. If the reversal is performed after ten years, the success rate may be further reduced to 25%.

The vasectomy CPT code 55250 procedure requires a specific time, and it may not deliver instant safety against pregnancy. 

Instead, use an alternative form of birth control until the provider confirms there are no sperms in semen.

Bilateral Vasectomy CPT Code

55250 can be billed as a unilaterally vasectomy CPT code or as a bilateral vasectomy CPT code (separate procedure), including post-operative semen examination. Usually, the vasectomy Procedure (CPT 55250) takes 20 to 30 minutes.

The anatomical modifier or laterality modifier is used to represent the procedure performed on the left side (modifier LT), right side (modifier RT), or bilateral side (modifier 50). Laterality modifiers are invalid with the vasectomy (CPT 55250) procedure.

Advantages Of The Vasectomy CPT Code 55250 Procedure

There are several advantages of the vasectomy CPT code procedure. A few of them are as:

  • A vasectomy procedure is recommended more often because it has a higher efficacy rate, i.e., 99%.
  • It does not affect hormones and sex drive.
  • It is a safe and simpler alternative to female sterilization.

Disadvantages Of The Vasectomy CPT Code 55250 Procedure

There are several disadvantages of the vasectomy CPT code procedure. A few of them are as:

  • It does not provide safety against STDs (sexually transmitted diseases).
  • It needs a lot of hard work to reverse.
  • Patients may use other methods for contraception after vasectomy until the provider confirms no sperms in semen.
  • The possible collection of blood inside the scrotum.

Billing Guidelines For CPT 55250

To make the person incapable of reproducing permanently through any medical-related procedure is designated as ‘sterilization.’ sterilization is a family planning procedure.

There are many other ways of family planning, but vasectomy (CPT 55250) is a simple and most effective procedure for preventing pregnancy.

In the USA, a third of couples attempt to protect pregnancy by choosing the sterilisation method. In males, vasectomy is the standard procedure for permanent sterilisation.

US government prohibits payment for the Vasectomy CPT code 55250 procedure until accurately completed an a federally approved sterilization consent form is received with a claim.

The federal consent for sterilization form FA-56 must be attached with the claim to get payment. The provider must obtain a copy of the completed consent form FA-56 to attach with the claim to fulfill this requirement.

While performing the vasectomy CPT code 55250 procedure, the insurance reimburses the payment when all the below-mentioned conditions are met.

The patient is at least 21 years old when consent is obtained.

The patient is neither mentally incompetent nor institutionalized.

The patient should not have used alcohol and other drugs.

The patient has voluntarily given informed consent and signed the sterilization consent form (FA-56).

The vasectomy must be carried out after at least 30-days of consent from the patient. But the consent form becomes invalid after 180 days.

The provider must inform detailed information about sterilization before the patient signs the consent form. The provider must advise about alternative family planning and birth control methods.

Also, the vasectomy CPT code 55250 procedure is an irreversible. The risk and benefits of sterilisation should be discussed before performing the procedure.

Prior authorization from insurance is not required to perform sterilization procedures, i.e., vasectomy. However, due to any complication, if the provider decides inpatient admission for a sterilization procedure, then it must be prior authorized.

A Medicare coverage guideline of vasectomy (CPT 55250) is limited to the necessary treatment of an illness or injury. Vasectomy in the absence of a disease for which sterilisation is considered a treatment is usually not covered. 

No payment is made for the sterilization procedure to be performed as a preventive measure of birth control.

For commercial insurance, if the sole purpose of vasectomy is related to family planning and contraception is processed for payment. However, a commercial payer does not pay for diagnoses and procedures unrelated to family planning.

As per MUE (medically unlikely edits) adjudication, an indicator is 2. The MUE edit policy allows the vasectomy CPT code 55250 only one unit.

It means it is permitted to bill only one unit on the same date of service. More than one unit in a single encounter is not allowed per CMS (Center for Medicare & Medicaid Services) guidelines.

An office visit related to the sterilization procedure is allowed to be paid on the day the vasectomy procedure is performed. Vasectomy is a 90-day global period procedure. 

Evaluation and management (E&M) with vasectomy are allowed, but the surgery modifier 57 is required with evaluation and management code. 

Insurance pays the office visit even if the patient does not choose sterilization.

While billing the vasectomy (CPT code 55250), the provider must use the current appropriate ICD 10 CM code to support the medical necessity.

The only diagnosis code for elective sterilization Z30.2 is applicable with vasectomy. Therefore, all sterilization claims must be billed with ICD-10 CM diagnosis code Z30.2 (encounter for sterilization) as the primary position.

Sterilization procedure must be billed with a specific place of services like provider office, ASC (Ambulatory surgical care), and inpatient hospital setting.

When a vasectomy procedure is performed alone or with any other unrelated procedure, it can be reported in a claim supported by medical documentation.

If the 55250 CPT code is accomplished with another operative procedure, the coder or biller must use modifier 59. But it should support the medical need.

Insurance pays for anesthesia with vasectomy when it is necessary. However, if multiple procedures are performed with sterilization, each procedure’s anesthesia time is calculated separately.

As per the description of vasectomy (CPT 55250), charges of post-operative semen examination are included in the procedure.

Post vasectomy semen analysis is used to verify the sterility. Sterility requires 20 ejaculations after the vasectomy procedure is performed. Usually, it takes three months to sterilize fully. 

Two semen tests should at least be considered to confirm the status of fully sterilized or sperm-free ejaculates.

While reviewing the medical documentation, the coder must keep in mind to select the correct codes to get the reimbursement. 

Accurate coding of sterilization procedure is a key for claim processing that includes proper selection of CPT code, diagnosis code, and modifier when necessary.

Medicare only pays for sterilization procedures when the provider documents that the procedure is medically necessary due to illness or injury.

Commercial insurances pay sterilization procedures if requirements are met fully. If the patient, provider, and other circumstances are met fully, the provider gets paid for the sterilization procedure.

Reimbursement For The Vasectomy CPT Code 55250

While coding Vasectomy CPT code 55250 procedures, selecting the correct code is essential because reimbursement depends on code selection.

The national physician fee schedule (PFS) for the facility for vasectomy is $231, and the fee schedule for non-facility is $346.

Therefore, incorrect selection of CPT affects the claim payment may be underpayment or overpayment.

Note: The history of vasectomy procedure code (CPT code 55250) was first introduced in Jan – 1993.

Modifiers

Modifier 26 and TC are not applicable with the vasectomy (CPT 55250) procedure. Still, if the provider is looking for increased payment because of extra effort or extra time, modifier 22 (increased procedural services) should be reported. 

Modifier 22 is valid with vasectomy; if the provider takes more time to complete the procedure due to any complication, modifier 22 must be used. Modifier 22 increases the price of the vasectomy procedure.

Modifier 53 is also a pricing modifier used when a procedure discontinues at any stage while performing procedure.

For example, when the provider finds any complications or severe medical conditions during the procedure, the provider decides to stop the procedure.

In such circumstances, modifier 53 represents that the procedure is discontinued. As a result, modifier 53 decreases the price of the procedure.

Modifier 59 is a payment eligibility modifier. Modifier 59 is used to represent distinct procedural services like CPT 55250.

Modifier 59 is used when multiple procedures are performed in the same setting, and more than one procedure is allowed to bill on the same day. Still, the modifier is required to distinguish two separate procedures. 

It is a prerequisite for the usage of modifier 59 that the claim must accompany the proper medical-related documents.

And the need for a distinct procedure must be provided if other procedures are executed on the same DOS (date of service). The provider’s responsibility is to mention the medical necessity for two different procedures performed in the same setting. 

When the vasectomy CPT code 55250 procedures is performed with another procedure (multiple procedures), and performed in the same setting, coding guidelines allow to bill them together. In this case, modifier 59 must be appended with column 2 CPT code. 

The addition of modifier 59 makes a claim eligible for the payment of two procedures. The covering companies only pay for the procedure with a lower RVU (relative value unit). 

It means the absence of modifier 59 may affect the reimbursement significantly so that the insurance companies may not pay for the procedure with a higher RVU (relative value unit).

Hence to get the payment of multiple procedures, the modifier 59 is necessary for reimbursement.

Example Of Vasectomy CPT Code 55250

A 48 years old patient came to the provider’s office with his partner of 35 years old female. She has two children; 5 years boy and two years girl. 

Now she does not want to have another child. Both parties were engaged in a detailed discussion and considered every possible way to prevent pregnancy.

Finally, after considering all aspects, the patient asked for a permanent solution to avoid pregnancy. Provider suggests a permanent method of sterilisation in the way of (Vasectomy).

The provider permanently sterilized the patient by vasectomy CPT code 55250 procedure in the above case. Therefore, the encounter of sterilization, diagnosis code Z30.2, is used with CPT code 55250. 

As the procedure is performed without any disease condition, government payers will not cover it.

Still, as commercial plans offer this procedure coverage with appropriate ICD – 10 CM, it should be billed with Z30.2 as a primary diagnosis to prove the medical necessity.

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