Medical billing(proceed with caution…)

Why is billing for a vasectomy complicated within the existing insurance systems? The charge that an organization bills for a vasectomy is typically for a procedure code (which in this case is CPT 55250). That procedure code is for a “bilateral vasectomy including postoperative semen analysis.” This covers the fee due to the physician, the team, and the supplies used during the procedure. It does not include a charge for:

  • Pre-vasectomy consultation
  • “Facility Fee”
  • Pre or post procedure medications
  • Laboratory charge if the surgeon sends a portion of the vas deferens to confirm that it is a portion of vas deferens
  • Pathologist fee to examine the slide prepared by the laboratory

The big-ticket item for a surprise high charge is the “Facility Fee.” The patient I referenced above who had a vasectomy at a nearby large medical center in June 2024 had almost $12,000 in charges, including a charge of $7711 for what the insurance company described as “Operating Room.” The patient did not have the vasectomy in an operating room, but rather it was performed in a clinic room, just down the hall from where he had his consultation two months earlier. There is a billing strategy, used by most medical centers to maximize their revenue, in which health system organizations categorize one room as a “Procedure Room” within their suite of offices. This then allows the organization to bill a “facility fee,” as though the procedure was done in an actual operating room.

A vasectomy consultation is typically performed in a very similar room, just down the hallway from the procedure. Interestingly the location for a vasectomy consultation is typically listed as “non-facility” charge, while the vasectomy itself is listed as a “facility” charge. Why? A consultation will be paid at a higher level if it is done in an outpatient office; a procedure will be paid at a higher level if it is in a facility. Billing practices like this are perfectly legal, but they are hardly transparent for the patient. Billing practices like this are challenging for a customer service representative at a Health System, outsourced billing company, or insurance company, to understand, let alone explain to an inquiring patient.

Other contributors to uncertain and high charges include whether a portion of the vas deferens is sent to the laboratory to be prepared for microscopic analysis by a pathologist. Dr. Curtis has long been of the belief that if you need a pathologist to tell you that you have correctly identified the vas deferens, then perhaps you should not be doing a vasectomy. The American Urological Association does not recommend sending the tissue for analysis as proof of a successful vasectomy because, by way of explanation, they point out that proof of vasectomy success requires a post vasectomy semen analysis.

The post vasectomy semen analysis is supposed to be a service included in the vasectomy bill (CPT 55250), but it is not uncommon for patients to receive a bill for the semen analysis from the laboratory that performs the test.

The aforementioned patient who shared his billing information with us (the $12,000 vasectomy) was flabbergasted at the charges and the opacity of the billing. At Twin River Urology we are doing it differently: One fee, $1200, including… everything.