Ob-Gyn Coding Alert

You can reap ethical reimbursement instead -- here's how If a patient presents to your practice complaining she is unable to get pregnant, you shouldn't automatically assume that you-ll be sacrificing payer reimbursement for this visit. Focusing on symptoms rather than 628.9 (Infertility, female; of unspecified origin) can make all the difference in how payers view your claims. Get to the Crux of the Problem Most insurance carriers will not reimburse for infertility treatments, and many payers balk when the word -infertility- pops up. -Infertility services always require intensive review prior to a patient's visit,- says Cheryl Ortenzi, CPC, billing and compliance manager of BUOB/Gyn in Boston. -In most cases, coverage is very specific. You have to verify coverage or lack thereof and review that with the patient so that everyone understands who is paying for these services.- Good advice: -Collect payment up-front for either the whole procedure (if the patient doesn't have any infertility benefits, such as for tubal reversal cases) or for their estimated portion (if the patient does have some coverage),- says Kimberly Horn, CPC, owner and operator of Village Coding at The Village, Okla. 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,- says Arlene Smith, CPC, CCS-P, health insurance coding specialist at Washington State Medical Association in Seattle. This is your opportunity to maximize ethical reimbursement by following two guidelines: 1. Stick to 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,- says Cindy Foley, billing manager for three ob-gyn practices in Syracuse, N.Y. 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. Keep in mind: You cannot report diagnosis codes for conditions your ob-gyn merely -suspects.- Example: A woman with pelvic pain (625.9, Unspecified symptom associated with female genital organs) comes in for an appointment, 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.

Solution: The ob-gyn's assessment and testing reveal 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 [...]