Ob-Gyn Coding Alert

A recent high-profile legal case in New York City has reproductive endocrinologistsas well as other medical practitionersstanding at the sidelines awaiting the outcome. The Feb. 7, 2000, issue of Time magazine reports on charges pending against New York gynecologist Niels Lauersen, who is accused of defrauding insurance companies out of millions of dollars. Lauersen allegedly submitted false claims to the insurance companies because the actual infertility procedures he was performing were not covered by his patients insurance. So a treatment for in vitro fertilization might be reported as the removal of an ovarian cyst, etc. The insurance companies claim that Lauersen bilked them out of as much as $4 million. Defenders of Lauersen claim that if he did fudge the records, it was to help his patients, many of whom could not afford the costly treatments and, subsequently, would never have gotten pregnant and had children.

The case brings to light a major problem for all gynecologists working with infertility treatments and in vitro fertilizationthe fact that most insurance companies simply do not pay for infertility treatments. As Susan Callaway Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., puts it, There are a lot of battles that are currently being fought in this arena, with the Lauersen case being the most high-profile one to date. With reproductive endocrinologists only just now beginning to get paid by insurance companies, its going to be an uphill climb for some years to come.

With so many insurance companies not covering even a portion of infertility treatments, practices often are requiring their patients to pay for the treatments in advance. In the rare instance where the insurer covers all or part of the procedure, a refund then is made to the patient.

Perhaps the most difficult aspect of insurance denials for infertility treatment is the emotional stress of patients who want to get pregnant but are unable to afford the procedures that could help them.

Lack of Understanding Is the First Stumbling Block

Callaway-Stradley explains that a big part of the problem with infertility treatments of all kinds is that insurance companies generally dont understand the steps involved in a process like in vitro fertilization. She visited Lauersens offices last year as a consultant, where she was shown around the fertility lab, and the extremely involved processes were outlined to her. Most people dont understand what is involved, she says. I certainly didnt before I visited.

Valerie Reno, billing representative for The Fertility and Reproductive Health Center, a group of fertility specialists in Annandale, Va., echoes Callaway-Stradleys contention that insurance companies dont realize what procedures are required for fertilization treatments. We have a few insurance companies who have approved infertility treatments for their patients, says Reno. For instance, theyve authorized a patient to undergo IVF (in vitro fertilization). But then they will reject certain codes that are an essential part of the IVF process as experimental and therefore not covered.

Reno elaborates: CPT code 89251 is for the culture and fertilization of an oocyte. It is consistently rejected by our insurers, yet we cant do an IVF without it. Reno says the same is true for code 89254 (oocyte identification from follicular fluid). They [the insurance companies] will say that we cant do both procedures on the same day, yet we have to do one in order to do the other. What were talking about is putting the retrieved female eggs in the dish with the sperm It is the whole basis of the IVF procedure.

Reno says she has had some success with reimbursement by preparing a boilerplate letter that accompanies her IVF claims. The letter outlines the steps involved in IVF, thereforeideallyeliminating the payers confusion.

What Is Likely to Get Paid

Insurers are more likely to cover the diagnostic aspect of infertilitythey will pay for determining what the problem is and for the process of elimination involved with reaching the diagnosis of infertility.

It is best to check with your patients carrier first to find out whats covered and whats not. But the following illustrates some of the testing and diagnostic codes likely to be covered.

If a female patient presents with the complaint that she is unable to become pregnant, use V26.2 (procreative management; investigation and testing). This code applies if the patient is displaying no other symptoms or complaints. Use of this code may help with payers who rejected claims with an infertility diagnosis at the first submission.

In the case of specific complaints, other diagnostic
codes apply. A patient complaining of problem periods would fall into the 626 category (disorders of menstruation and other abnormal bleeding from female genital tract). The most common possibilities here include 626.0 (absence of menstruation), 626.1 (scanty or infrequent menstruation), 626.2 (excessive or infrequent menstruation) and 626.4 (irregular menstrual cycle). A large number of testing possibilities exist to determine whether a patient is infertile. Following are the most commonly used tests:

To check for ovulation factors, the physician may
order a follicle stimulating hormone test (83001) or a
luteinizing hormone test (83002).

Echography, transvaginal (76830) may be performed
to check on the formation of ovarian follicle.

A battery of semen analysis tests might be conducted, including semen analysis (89300, semen analysis; presence and/or motility of sperm), sperm count (89310) or a complete sperm analysis (89320). Code 89325 reports sperm antibodies, a test that would monitor the overall health of sperm and a cervical mucus penetration test (89330) would detect whether cervical mucus was hostile to sperm.

Hysterosonography (76831 for supervision and interpretation, plus 58340 for the injection of the
dye) to check on the contour of the uterus and the
patency of the tubes.

An endometrial biopsy (58100, endometrial sampling with or without endocervical sampling, without cervical dilation, any method) might also be performed to check on the maturation effect of the endometrial lining on the female, or a diagnostic laparoscopy (49320) might be done to check on possible causes of infertility such as adhesions or other problems.

Is Infertility a Condition or a Disease?

Another problem is the tendency for insurance companies to regard infertility as a condition rather than as a disease. As a result, insurance companies pay for all the tests and procedures done up until the point of diagnosis, then they refuse to pay for treatment of the diagnosed problem. When the practice submits diagnostic codes for infertility, the claims processor sees the diagnosis and disregards the procedures leading to it. The result is a denied claim.

Renos physician, Pierre Asmar, MD, reports difficulty with one code in particular, ICD-9 code 628.9 (infertility, female, of unspecified origin). In Asmars view, the code indicates that he is trying to determine the cause of infertility, therefore conducting ultrasounds, blood work, etc. Even though no treatment has been started, says Reno, many insurers will reject the claim flat out because of the diagnosis. Reno says that Asmar (as well as other practitioners) definitely regards his patients infertility as a disease that needs to be treated as suchnot just a condition that they should be expected to live with.

The lack of understanding of this fast-growing and rapidly progressing area of medicine is compounded by the fact that coding and nomenclature generally cant keep pace with the technological advances in fertility treatments. New developments are being implemented long before codes are available to classify them. The result is the use of a lot of unlisted procedure codes, which more often than not mean a red flag with insurance companies.

Its a lot of work for us, as office staff, to understand all the procedures, says Reno. But if were the ones who have to fight for reimbursement and fight on our patients behalf, we have to know what our doctors and technicians are doing.

Is Help on the Horizon?

When we told Reno about Lauersens alleged submission of false claims to help his patients, she shared her clinics less drastic methods of helping to bridge the coverage gap. We have a staff person whose sole job is to verify patient benefits up front. When we find out what infertility treatments are not covered, we arrange for a flat fee for whatever treatments the patient(s) needs. We take into account what sort of adjustments we would be encountering with insurance companies, deductibles, etc., and arrive at a figure that most of our patients can live with.

Reno also maintains that things are getting better with regard to insurers paying for infertility treatments. A lot more insurers are paying now than used to. Some that didnt pay last year are paying this year, and I expect it will keep improving. Our best defense is to know in advance what is and isnt paid for by our patients carriers.

Still, Callaway-Stradley contends that if Lauersen is convicted of fraud, It will be a wake-up call to the entire industry. Hopefully, the end result will be a lessening of restrictions by insurers, and a more patient-focused approach to coverage.