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Questions:

Infertility | Insurance Denial | IVF | Specific Procedures | Office Mgmt

General Infertility Treatment Questions:

1. There are two new codes and revisions were made to the existing semen analysis codes to clarify their intent.
   
   PART TWO: Our physicians do the retrograde semen analysis. What CPT/CPTs would you suggest we use?

2. I am trying to get some guidance on the correct way to bill for the diagnosis part of Procreative Management. I understand that when a patient is going through the diagnostic portion of determining the reason for infertility, you would use the appropriate ICD.9 code to indicate the reasons for the test. My question is: Once we have determined that the patient is infertile, and we want to go ahead with the IVF process, would it be appropriate (is it required) to use the V26.9 code as the primary diagnosis and the reason for the infertility as the second diagnosis? The second part of my question is do you have some guidance on what else would be considered procreative management?
   
   PART TWO  - New ICD-9 codes for 2008: Natural family planning for contraceptive and procreative management

3. The CPT coding info for ART labs you provide is very useful. Do you have information on endocrine lab testing -- specifically, CPT codes and typical reimbursement from third-party payers? Also, how does reimbursement for diagnostic endocrine testing differ from endocrine monitoring for the treatment cycle? Are there other diagnostic andrology procedure codes and reimbursement for tests such as the cervical mucus penetration test, etc., that you did not list in the "correct coding for lab procedures during ART cycle" publication?

4. How soon can you bill as a new infertility patient? If a patient has not been seen since 2004 for infertility and is now returning for infertility in 2006, would they be considered a new patient? What is the time frame to bill again as a new patient?

5. What code is used for a nurse practitioner seeing a fertility patient for the first time?

6. What code would be appropriate for an initial visit for infertility? Our practice is in a state where there is no mandated coverage for infertility. We are finding that many insurances will not cover if the word “infertiliy” is used.

7. That is the correct ICD-9-CM Coding for screening tests performed by physicians treating infertility patients?

8. Our reproductive endocrinologist sees patients for recurrent miscarriages. When he sees the patient for the first visit, is it appropriate to use the diagnosis codes V26.4 (procreative management) as a primary code and 629.9 as a secondary code?

9. If we have a patient who self-refers to our physician for an initial new patient consultation as opposed to being referred by another physician, how do we code for the consult? Also, when our physician brings the patient back into the office for a follow-up consultation to discuss diagnostic results and treatment recommendations, how do we code? Both of these consultations include approximately one hour of face-to-face time with the physician.

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Insurance Denial:

1. First Trimester Ultrasound Denials

2. We have been struggling with 58660 lysis of adhesions and insurance reimbursement. Most insurance companies are denying this code when billed with another laparoscopy such as 58661 or 58662, etc., stating these codes are bundled. According to the AMA, in March of 2003, 58660 can be billed in addition to the primary procedure only if “dense/extensive adhesions are encountered that require effort beyond that ordinarily provided for the laparoscopic procedure.” What is a “normal” amount of adhesions, and is this based on a timing structure (i.e., how long it takes to lyse the adhesions)?

3. Is another code other than V26.21 or V26.29 for pre-IVF testing that insurance will NOT deny?

4. As a gynecologist, all my patients are female. I have a patient with suspected male infertility. When I order a sperm test on the male partner it is routinely denied by her insurance. Our office has confirmed that she has coverage for infertility. How can I solve this problem?

5. Excuse me, but I did that twice! Explain more about relative value units (RVU).

6. We have received denials from insurance payers when billing CPT code 89251.  The denial indicates “experimental in nature, not FDA approved.”  I understand that CPT codes are not approved by FDA, but by the AMA.  Can you advise with appealing this denial?

7. My insurance company is bucking me on paying for frozen embryo transfer.  They say because it is experimental.  I want to know if this is still considered experimental or if it is a FDA approved procedure.

8. I saw a patient for consultation who had irregular uterine bleeding. After I evaluated her, I performed an endometrial biopsy. The insurance company denied the consultation and only reimbursed me for the endometrial biopsy. Shouldn’t I have been paid for both? 

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IVF Questions:

1. Important new ICD-9 Diagnosis Codes for 2008 Patient Undergoing Assisted Reproductive Technology

2. Are we allowed to bill professional charges under the physician for the embryologist who performs the IVF laboratory services (ICSI, hatching, cultures)?

3. In accordance with ASRM practice guidelines, many REs require patients (and their spouses/partners) who are considering using donor gametes to see an infertility counselor first.  Assuming the purpose of these consultations is to explore relevant psychosocial issues, rather than to evaluate "suitability" for treatment, how should they be coded by the infertility counselor?

4. I am seeking information on IVF insurance billing guidelines.  When billing the lab procedures do you use a 1500 claim form only or in combination with the UB92? I am referring to: 58970, 58974, 89280, 89281, 89255, 89352, 89258, and 89253.

5. What code should be used for a vaginal probe ultrasound done to check for follicles during ovulation induction -- 76857 or 76830-52? We are planning to open an IVF lab that is not contracted with insurance companies. The stimulation portion of the IVF cycle will be rendered by the physician’s practice which is contracted with insurance. The retrieval, transfer, embryo culture, etc., will be provided by the IVF lab, those services will be paid by the patient, and the patient will seek reimbursement from her insurance if she has coverage. The same physician that monitors the ovulation induction portion of the cycle will be doing the retrievals and transfers in the lab. Is it appropriate to bill the physician's fees for the retrieval (58970) and transfer (58974) under the IVF lab since that is where the service will be provided? Or should those fees be billed under the physician's practice?

6. Where can I find a list of the new codes for ART Laboratory procedures?

7. One of the problems that we are having is coding for the management cycle. Coding for insurance companies for in vitro fertilization is still quite new to us. Can you help?

8. What is the correct way to bill and receive payment for the patient education sessions performed by registered nurses to individual patients prior to their IVF cycle? We typically spend at least one hour with each patient and partner discussing instructions and protocol for their ovulation induction.

9. Does the Insurance Industry have a designated CPT code for the “cryopreservation and storage” of reproductive cells and tissue?

10. How do you submit billing when a patient has insurance coverage for donor egg retrieval? It also pays for medications (i.e., Antagon®, RepronexTM, and Follistim® for the egg donor). What CPT codes should be used if an egg donor is used?

11. What is the correct way to bill cryopreservation of embryos (89258)?  If you have multiple days of freezing for one patient's embryos, can you bill each day of freezing or just the initial freeze?  Does the code 89258 include the storage?
    
    PART TWO - I am writing in regards to this question, because I am interpreting this as though a provider should NOT be billing 89258 for cryopreservation of embryo & storage of embryo. Am I interpreting this correct? Or can a provider bill storage under this code, just with an increase fee?  I came across your website because a friend is having a difficult time getting her provider to bill embryo storage because they state this code is for freezing only. And there is no appropriate code to use for storage. Can you please help with this situation?

12. If an IVF embryo extraction and transfer is performed at an ambulatory surgical center (ASC), can the ASC bill third-party payors a facility fee? Can they bill such a fee in addition to what the IVF physician and the embryology lab may bill?

13. We have a hospital-based embryology lab that is headed by a physician. We are billing for the technical component of 89250 and would like to also bill a professional component of the 89250. We have not been able to support the professional billing of this code (89250). After extensive research, we cannot find anything definitive. It seems to me that there is sufficient physician involvement to generate a professional fee. This code does appear on at least one of our contracted payment schedules but does not appear on the Medicare physician fee schedule.

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Coding for Specific Procedures:

1. New CPT Codes for 2008 Laparoscopic Total Hysterectomy

2. If a woman requires a gestational carrier, how is the gestational carrier coded? She is truly not a surrogate, just gestational. 
   
   PART TWO - What is the appropriate ICD-9 code for a surrogate carrier? Can you make a recommendation?

3. Our clinic is just starting to do PGD. We currently are flying in an embryologist from out of state to do this procedure for our patients. I have a patient who might have insurance benefits for PGD. Since we are not physically doing the procedure, but are flying in/out the embryologist who prepares the slides, then completes the procedure in his/her own lab, can we bill the insurance? For self-pay patients, we currently collect a one-lump fee, and out of that fee, we pay air fare, hotel, eating expenses, and the embryologist’s professional charges and laboratory charges. We haven’t had to deal with a patient and insurance for this type of service before.
   
   PART TWO - I am trying to identify the correct CPT code for preimplantation genetic diagnosis (PGD). Could you help?
   
   PART THREE - Have any new codes been introduced for the lab portion of preimplantation genetic diagnosis (PGD)?
   
   PART FOUR - What would be the diagnosis code for PGD performed due to a genetic disorder (fragile x syndrome)? Would I use 628.8 for female infertility -- although this is really not correct?

4. How do I code for therapeutic donor insemination for an unmarried female with no known fertility issues except no partner?
   
   PART TWO - Is there a code that can be used for donor sperm?

5. What is the code to use for COH (Controlled Ovarian Hyperstimulation): managing the patients, dosing of HMG, etc.?
   
   PART TWO - When our doctor does a paracentesis for a patient with ovarian hyperstimulation, what would be the best CPT code to use? We are considering using 49080. Can this be used with 76942 when ultrasound guidance is used, or do we need to pick one or the other?

6. Does the code for intrauterine insemination (IUI) (58322) include the office visit (E/M) for that day, or is that only for the actual procedure?
   
   PART TWO - Our physician currently does all of his own IUIs. We have recently hired an R.N. who has performed IUIs. We are thinking of having her help with our busy cycle months. Can we bill an insurance company for an IUI performed by a nurse? Does the physician have to be present in the office and sign off on office notes? Are there any legal concerns with malpractice in having the nurse perform these services instead of the physician?
   
   PART THREE - At our center the intrauterine inseminations are performed by our nurses.  At the time of the insemination our nurse assesses the patients for any symptoms, reviews an instruction sheet that educates the patient about the symptoms of ovarian hyperstimulation, tells the patient when to come in for the pregnancy test and reviews any additional physician instructions.  In addition to all of the standard charges for the insemination and sperm prep can we also bill the evaluation management code 99211 with a modifier (-25)? 

7. I need a CPT code for microsurgical epididymal sperm aspiration. Could you help?

8. Is there a code for Tompkins Metroplasty?  Our physician performed this procedure recently, and we are unable to determine the appropriate code to file our claim.

9. Is there a CPT Code for "Ovarian Drilling"?

10. How do you code for a hysterosalpingogram or saline hysterosonogram?
    
    PART TWO -  If the answer is “if you perform the injection of contrast for an HSG at a radiology facility, you can report 58340: introduction of saline or contrast.”  Should you not also bill 76831-26?

11. Have CPT codes been established for Maturation In Vitro? If so, what are they?

12. How do you code for Ultrasonography performed at the time of an embryo transfer?

13. I looked through the “Ob/Gyn Coding Manual” and have not found a code for a mock embryo. How can I report this procedure?

14. Is there a code for laparoscopic lysis of omental adhesions? Our coder showed me enterolysis, tubolysis, ovariolysis , etc but I didn't think any of those were right.

Office Management Questions:

1. Does a physician need to speak directly to a patient to code for a telephone consult (99371-99373) or can a physician give specific instructions to a staff member to relay to patients? Patients can be difficult to contact and physicians have limited time during the day. For example, if a nurse relays information that a pregnancy test is negative and that the patient should start her BCP on Sunday, would this be appropriate to code as 99371? 

2. Can you please clarify the intent of the CPT codes for telephone calls? Specifically I am interested in understanding when it would be appropriate to use the CPT codes 99371, 99372, and 99373. Most reproductive clinicians routinely coordinate medical management or have regular contact with their patients, either directly or indirectly by phone, multiple times during an ART or IUI/FSH cycle. Is it appropriate to bill for these codes in association with ren­dering daily test results (E2, ultrasounds, etc.), advising patients of daily gonadotropin dosages, answering routine questions and/or discussing future plans? Or is it not appropriate to bill separately for these items as they are part of routine infertility care?

3. Can a privately owned office facility dedicated to IVF services and embryology lab bill a facility fee to insurance companies?