Ob-Gyn Coding Alert

Although payers generally don't pay for polycystic ovarian syndrome (PCOS) because they interpret it as infertility, there are steps you can take to ensure carriers reimburse you for your services associated with the condition.
 
Before the physician establishes a PCOS diagnosis, you can report the patient's signs and symptoms to get paid for the doctor's services. But once the ob-gyn has established the PCOS diagnosis, you should link any treatments for the condition to 256.4 (Polycystic ovaries). Consequently, payers likely will deny payment. But you can work with your carriers by explaining that PCOS does not equal an infertility diagnosis and that it carries a whole series of additional symptoms that affect a patient's heath, coding experts say. You can also negotiate to have treatments for PCOS included in any contracts with carriers.
 
If this doesn't work, take steps to eliminate payers' bias against practices that diagnose PCOS. Write a letter to the medical director, carbon copy the state insurance commissioner, and say, "This is discrimination against this patient because I listed the diagnosis as PCOS, and you're turning it down for a diagnosis that wasn't listed on your local medical review policy."
 
On the other hand, there are several major payers that offer infertility as a covered benefit, says Peggy Stilley, CPC, office manager for Women's Healthcare Specialists, an Oklahoma University-based private
ob-gyn practice in Tulsa. Consequently, you should know your payers and verify patients' coverage, making sure that they are aware of the possibility of having large bills to pay, she adds.