Ob-Gyn Coding Alert

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.

"If the patient just says, 'pelvic pain' or 'irregular menses,' it would really help the backup documentation," Schraufnagel says.

Once the endometriosis has been treated, many women get pregnant right away, and fertility never becomes an issue. In fact, the ob-gyn's documentation never need mention infertility, except perhaps as a secondary diagnosis.

Watch out: Ob-gyns often rely heavily on patient histories during the first visit. And any physician likely will 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 as long as the physician focuses the documentation on those.

"Too much emphasis on infertility, though, will certainly make a payer deny your claim if they review the records," Richardson warns. "The process here is to treat the patient's presenting problem -- endometriosis."

2. Don't Downcode a Consultation

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 her to your ob-gyn. If this is the case, you can get paid for a consultation (99241-99245) as long as the ob-gyn documents the required components. Remember to check for the three "R's" -- request, review and report. For the visit to qualify as a consultation, the patient's primary physician must request the opinion of your ob-gyn, the ob-gyn must review the patient's condition via exam and then report his findings back to the requesting doctor.

For example, a woman presents with irregular menses (626.4, Irregular menstrual cycle) and cystic acne (706.1, Other acne) 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 problem-focused history and exam and some diagnostic testing, the ob-gyn determines that the patient indeed does have PCOS (256.4, Polycystic ovaries). 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 course of treatment. In this case, you should report a consultation based on the extent of service the documentation indicates. You should include as diagnoses 626.4, 706.1 and 256.4.

Warning: Be careful not to use only 256.4 because carriers often lump this with infertility treatment and may refuse to pay. "Remember the prime reason the patient was referred to your practice -- irregular menses and cystic acne -- to help you determine the ICD-9 codes you submit," Richardson says.