Tips to Stay Away from Initial Infertility Denials

Here are some tips to help you maximize your ethical reimbursement for initial infertility:



You may be persuaded to code for an initial infertility visit as an office visit, but this may not be the case. Often, a woman's primary-care physician will refer her to your ob-gyn. In this instance, you may get paid for a consultation (99241-99245) as long as the ob-gyn documents the required components.



Ensure 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 figure out the reason for a consult and request the opinion of your ob-gyn. The ob-gyn must render an opinion based on the review the of the patient's history and exam. In the end, the ob-gyn must then report his findings and recommendations and return the patient back to the requesting doctor.



Here's an 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 doctor suspects ovulatory dysfunction or polycystic ovarian syndrome (PCOS) and would like your ob-gyn's opinion. Post 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. Post the visit, the ob-gyn sends a report to the requesting doctor outlining the findings and proposed course of treatment.



Answer: In this instance, you'd report a consultation based on the extent of service the documentation points to. At present, you most likely have moderate medical decision making but only a problem focused history and exam. As such, this would be a level one consultation (99241). You should include 256.4, 626.4, 706.1 as diagnoses. You'll list the 256.4 as your primary diagnosis since this is more specific than a diagnosis of irregular periods and you always code what you know at the end of the visit if it is more specific than the original reason for the visit.



But be careful not to use only 256.4 since carriers often lump this with infertility treatment and may refuse to pay.



Also, remember why the primary physician referred the patient is not always the proper ICD-9 code at the end of the visit. If the family physician referred the patient for suspected fibroids (218.x) causing infertility, and the Ob-gyn does a sonogram that doesn't show any fibroids, you should not use fibroids as your finding.



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