Avoid the infertility coding trap by going beyond 628.9
If you're offering infertility treatments for your patients, you don't have to sacrifice carrier coverage for initial visits. Using diagnosis codes other than 628.9 (Infertility, female; of unspecified origin) can make all the difference in how payers view your claims.
Most insurance carriers will not reimburse for infertility treatments, and many payers balk when the word "infertility" pops up. "You should know exactly what your payers do and do not cover, because some plans will pay for the workup and/or testing while others may not pay for any services related to infertility," suggests Judy Richardson, RN, MSA, CCS-P, a senior consultant at Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C. You should tell patients up front what expenses they may incur for these services, she adds.
"Our problems arise when the patient makes the appointment for an 'infertility' evaluation and lists her chief complaint or reason for exam as 'infertility,' " says Penny Schraufnagel, office manager for Ob-Gyn Center PA in Boise, Idaho. "She tells the doctor she is having problems getting pregnant and wants an 'infertility' exam, and he documents the reason."
Even so, many private payers will cover the first or second visit, so this is your opportunity to maximize ethical reimbursement by following two guidelines:
1. Stick to the Presenting Symptoms
Infertility issues may never enter the picture if your ob-gyn effectively treats a patient's presenting symptoms. You should educate your physicians to document the patient's condition(s) using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the encounter, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "Providers need to know that they should never report diagnosis codes for conditions that are 'suspected' or 'rule out' conditions."
Example: A woman with pelvic pain comes in for an appointment (625.9, Unspecified symptom associated with female genital organs), and the physician focuses on this problem. The doctor discusses infertility as a secondary symptom because the patient's more urgent problem is her pelvic pain.
The ob-gyn's assessment and testing reveals the patient has endometriosis (617.0, Endometriosis of uterus), and the treatment plan is surgery. In this case, you should report the initial E/M service as a consultation (99241-99245) if the patient's primary-care physician has requested the ob-gyn's opinion, Mulholland says. On the other hand, if the ob-gyn initiated the service, you would submit an office visit code (99201-99205 for new patients, and 99211-99215 for established patients). Be sure to submit 625.9 as the primary diagnosis, she adds. For subsequent visits and the surgical treatment, you should use 617.0 as the primary diagnosis.