ICD 10 Coding Alert

Hint: Consultation codes can come in handy.

Although a general rule of thumb is to code for diagnosis, when it comes to fertility, focusing on the symptoms may be helpful to get claims paid.

Some payers may balk when they see N97.9 (Female infertility, unspecified), so knowing how to document a patient’s situation without giving payers pause can make a huge difference.

‘Infertility’ May Be a Red Flag

Most insurance carriers will not reimburse for infertility treatments (these treatments are only mandated in 18 states in the U.S. currently: go to https://www.healthinsurance.org/faqs/does-the-aca-require-infertility-treatment-to-be-covered-by-health-insurance), and many payers balk when the word “infertility” pops up, says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Infertility services always require intensive review prior to a patient’s visit, experts say. In most cases, coverage is very specific. You must verify coverage, or lack thereof, and review that with the patient so that everyone understands who is paying for these services.

Maximize ethical reimbursement by following two guidelines:

Step 1: Note the Presenting Symptoms

Generally, the initial “infertility” visit isn’t really about the infertility because the cause of infertility is rarely known. The patient has an initial symptom or complaint that is the primary diagnosis or reason for this visit.

In other words, 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.

Red flag: You cannot report diagnosis codes for conditions your ob-gyn merely “suspects.”

Example: A woman with pelvic pain (R10.2, Pelvic and perineal pain) comes in for an appointment and mentions during the evaluation that she has been trying to conceive for the past year. The physician focuses on the cause of the pelvic pain. The doctor discusses infertility as a secondary symptom because the patient’s more urgent problem is her pelvic pain.

Solution: The ob-gyn’s assessment and testing eventually reveal the patient has endometriosis (code category N80.0-, Endometriosis of uterus), and the treatment plan is surgery. But be sure to submit R10.2 as the primary diagnosis for the first visit. For subsequent visits, once the physician diagnoses endometriosis and the surgical treatment, you should use an N80.0- code that best describes the severity of the endometriosis found as the primary diagnosis.

Once the ob-gyn treats the endometriosis, many women become pregnant right away, and fertility never becomes an issue. In fact, the ob-gyn’s documentation never needs to mention infertility, except perhaps as a secondary diagnosis, Witt says.

However, if the main reason for the visit is an inability to conceive or a history of infertility, you may have cause to expect a denial.

Watch out: Ob-gyns often rely heavily on patient histories during the first visit, and any physician will likely include a discussion of pregnancy and fertility issues as part of this history. Don’t let payers bully you by saying that this indicates treatment for infertility. You are correct to report other symptoms as diagnosis codes if the physician focuses the documentation and evaluation on those issues.

Step 2: Consider Consultations

You may be tempted to code for an initial infertility visit as an office visit, but this may not be the case. Frequently, a woman’s primary care physician will refer them to your ob-gyn.

If this is the case, you can get paid for a consultation (99241- 99245) when the payer covers them if the ob-gyn documents the required components, and there is a clear request for an opinion or advice by the primary care physician.

Remember to check for the “five Rs” — reason, request, render, report, and return — says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. For the visit to qualify as a consultation, the patient’s primary physician must determine the reason for a consult and request the opinion of your ob-gyn. The ob-gyn must render services and review the patient’s condition via an examination and evaluation. Finally, the ob-gyn must report their findings and return the patient back to the requesting doctor.

Example: A woman with irregular menses (N92.6, Irregular menstruation, unspecified) and cystic acne (L70.0, Acne vulgaris) presents to your ob-gyn at the request of her primary physician. The primary physician suspects ovulatory dysfunction or polycystic ovarian syndrome (PCOS) and would like your ob-gyn’s opinion. After a detailed history and exam and some diagnostic testing, the ob-gyn determines that the patient does indeed have PCOS (E28.2, Polycystic ovarian syndrome). The ob-gyn discusses infertility only as a secondary symptom during the course of the history. After the visit, the ob-gyn sends a report to the requesting physician outlining the findings and proposed treatment course.

Solution: In this case, you should report a consultation (99241-99245) based on the extent of service the documentation indicates. You should include as diagnoses N92.6, L70.0, and E28.2.

Heads up: Be careful not to use only E28.2 because carriers often lump this with infertility treatment and may refuse to pay.

Rule of thumb: Experts say that everything boils down to determining if infertility is secondary or primary — and you’d better be able to substantiate that.

Even if the only reason for the visit is “I can’t get pregnant,” some payers will cover the first or second visit. And some payers will cover services that determine the condition of infertility.