The Secret to Getting Paid for Initial Infertility Visits

You don't have to sacrifice carrier coverage for initial visits just because your reproductive endocrinology practice specializes in infertility treatment. Using diagnosis codes other than unexplained infertility - 628.9 (Infertility, female) and 606.9 (Infertility, male) - can make all the difference in how carriers view your claims.

Coverage for infertility treatment is not common, and many insurance carriers balk whenever the word "infertility" pops up. "We find that probably about 80 percent of our patients do have diagnostic coverage for infertility, but that's very limited," says Brenda Messick, CPC, business manager at Georgia Reproductive Specialists in Atlanta. The diagnostic stage for infertility usually takes only one or two visits. "After that point, I'd say only about 35 percent of our patients have coverage for treatment," Messick adds.

You find the most coverage for the first or second visit, so this is also the period when you can maximize reimbursement by coding for all the symptoms presented.
Be Open to Other Diagnoses
When a patient comes for her first visit, "There could be any number of things going on" other than infertility, says Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C. These are the symptoms you need to focus on in your diagnosis coding. Physicians often think that because they specialize in infertility they won't get paid, even if they are seeing a patient for other symptoms. Not true. Reproductive endocrinologists need to stop shying away from other diagnoses and code for all the symptoms a patient presents with, Richardson says.

For example, a woman may visit a reproductive endocrinologist because she's been having severe pelvic pain (625.9), irregular menses (626.4), or heavy bleeding. In the process of taking the history, the physician determines that the woman is trying to get pregnant but has been unable. You would code for the presenting symptoms with infertility as a secondary diagnosis, if anything. The physician needs to be careful to stick to the primary reason why the patient is there and only mention infertility as a secondary concern in his documentation.

Watch out: Too much talk of infertility makes it difficult to code for the primary presenting symptoms, Messick says. If the documentation for the visit focuses too much on infertility, it will invalidate your records for reimbursement if the carrier asks to see them, she adds.
Focus on Other Symptoms
Of course, there will be many situations in which the patient comes in and says up-front, "I've been treated for infertility before" or "I can't get pregnant and I have no idea why." In these cases, you have little choice but to code for infertility on the very first visit, Messick says.

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- Published on 2004-02-10