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checking testosterone levels in a FTM transgender patient

I’m hoping someone can offer some input.

Provider wants to check the testosterone levels in a FTM transgender pt. He is using the dx of male hypogonadism.

The coders in our office are wondering if this is an appropriate dx?

Our thinking is that since he is taking testosterone externally, the issue is not about testosterone production or, if it is about testosterone production, it is not produced in the testes. We don’t have enough of his medical history, so we are unsure if ovaries are intact, but are assuming they are not.

We’ve been researching this and have found lots of information about the importance of checking his testosterone levels, but nothing about what dx to use for the testing.

Does anyone have any information about this?
Thanks in advance,
Lisa

Medical Billing and Coding Forum

E/M code with weekly testosterone injections

Can I bill a 99212 if my midlevel is seeing the patient and performing a review of systems and a focused based exam? She also administers the injection herself. I was taught you can not bill an E/M code if the patient is scheduled for a weekly injection based on CMS rule from 2004. Our patients are expected to return every 7-10 days. My midlevel states since she is doing the work, therefore, she should be paid for what she does. So she wants me to bill 99212-25, 96372 and J1071, who is correct? Can someone help me with this issue?

Medical Billing and Coding Forum