Ob-Gyn Coding Alert

Symptoms, not infertility, may help your initial visit claim pass muster.

Don’t settle for infertility visit denials when a patient presents to your practice complaining she is unable to get pregnant. 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, experts say.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.

Maximize ethical reimbursement by following two guidelines:

Step 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.

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 (625.9, Unspecified symptom associated with female genital organs) comes in for an appointmentand 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 (617.0, Endometriosis of uterus), and the treatment plan is surgery. But, be sure to submit 625.9 as the primary diagnosis for the first visit. For subsequent visits once the physician diagnoses endometriosis and the surgical treatment, you should use 617.0 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 need mention infertility, except perhaps as a secondary diagnosis.

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 as long as the physician focuses the documentation on those issues.

Step 2: Avoid Overlooking 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 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, and there is a clear request for an opinion or advice by the primary-care physician.

Remember to check for the “five R’s” -- reason, request, render, report, and return. 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 exam. Finally, the ob-gyn must then report his findings and return the patient back to the requesting doctor.

Example: A woman with irregular menses (626.4, Irregular menstrual cycle) and cystic acne (706.1, Other acne) 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 problem-focused history and exam and some diagnostic testing, the ob-gyn determines that the patient does indeed 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 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 626.4, 706.1, and 256.4.

Heads up: Be careful not to use only 256.4 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.

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).

Even if the only reason for the visit is “I can’t get pregnant,” some payers will cover the first or second visit.

Some payers will cover services that determine the condition of infertility.