What diagnosis code is used for testosterone pharmacy orders?

Diagnosis Codes for Testosterone Pharmacy Orders

The appropriate ICD-10 diagnosis code for testosterone pharmacy orders is E29.1 (testicular hypogonadism) for primary hypogonadism or E23.0 (hypopituitarism) for secondary hypogonadism, but testosterone therapy should only be prescribed when both biochemical confirmation (two morning total testosterone levels <300 ng/dL) AND clinical symptoms of hypogonadism are documented. 1

Diagnostic Requirements Before Prescribing

Testosterone prescriptions require proper diagnostic documentation to justify medical necessity:

• Two separate morning testosterone measurements (between 8-10 AM) showing levels consistently <300 ng/dL are required for biochemical confirmation 1, 2
• Clinical symptoms must be documented, including reduced libido, erectile dysfunction, decreased energy, reduced muscle mass, or diminished sense of vitality 1, 2
• Physical examination findings should document body habitus, BMI/waist circumference, virilization status, gynecomastia, and testicular evaluation 1

Establishing the Correct Diagnosis Code

The specific ICD-10 code depends on the etiology of hypogonadism:

Primary Hypogonadism (E29.1)

• Characterized by elevated LH/FSH with low testosterone, indicating testicular dysfunction 1, 2
• Measure serum LH and FSH after confirming low testosterone to establish primary vs. secondary etiology 1, 2, 3

Secondary Hypogonadism (E23.0)

• Characterized by low or low-normal LH/FSH with low testosterone, indicating hypothalamic-pituitary dysfunction 1, 2
• Measure serum prolactin if LH is low or low-normal to screen for hyperprolactinemia 2, 3
• Consider pituitary MRI if secondary hypogonadism is confirmed 2

Additional Diagnostic Codes for Specific Conditions

• E89.5 for postprocedural hypogonadism (after orchiectomy, radiation, chemotherapy) 1
• Z79.899 for long-term use of other medications causing hypogonadism (opioids, corticosteroids) 1
• E66.9 for obesity-related functional hypogonadism 1

High-Risk Populations Requiring Testosterone Assessment

Measure testosterone even without symptoms in patients with: 1, 3

• Unexplained anemia
• Bone density loss or osteoporosis
• Type 2 diabetes mellitus
• HIV/AIDS
• Chronic narcotic use
• History of chemotherapy or testicular radiation
• Pituitary dysfunction
• Chronic corticosteroid use

Critical Documentation to Support Pharmacy Coverage

Insurance coverage requires documentation of:

• Symptoms consistent with hypogonadism - reduced libido, erectile dysfunction, fatigue, decreased muscle mass 1, 4
• Two morning testosterone levels <300 ng/dL measured on separate occasions 1, 2
• LH/FSH levels to establish primary vs. secondary hypogonadism 1, 2, 3
• Discussion of risks and benefits with the patient before initiating therapy 1, 5
• Absence of contraindications including active prostate or breast cancer, desire for fertility, severe untreated sleep apnea, or recent cardiovascular events 1, 5

Common Pitfalls to Avoid

Up to 25% of men receiving testosterone therapy do not meet diagnostic criteria for hypogonadism 1, which can result in denied pharmacy claims. Avoid these errors:

• Never prescribe based on symptoms alone without biochemical confirmation 1, 6
• Never measure testosterone at random times - afternoon/evening levels are physiologically lower and lead to false-positive diagnoses 2, 3
• Never use screening questionnaires alone to diagnose hypogonadism due to lack of specificity 1, 2
• Never prescribe testosterone to eugonadal men (normal testosterone levels) even if symptomatic - this is explicitly contraindicated 1, 2
• Never prescribe testosterone to men actively seeking fertility - use gonadotropin therapy (hCG plus FSH) instead 1, 2, 5

Functional Hypogonadism Considerations

For obesity-related or metabolic syndrome-associated hypogonadism:

• Document underlying conditions (obesity, diabetes, metabolic syndrome) with appropriate ICD-10 codes 1
• Lifestyle modifications should be attempted first - weight loss through low-calorie diets can reverse obesity-associated secondary hypogonadism 1, 2
• Consider combining lifestyle interventions with testosterone therapy for symptomatic patients 1