Coding and Billing for Infertility services and procedures
Originally Published: July 16, 2016
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC
Infertility is one of those topics that not many men or women openly discuss. In the medical community, we look at this as a diagnosis that needs evaluation and treatment, if there are viable options available for you.
According to the AIUM (American Institute of Ultrasound in Medicine©) they define female infertility as:
"Female infertility shall mean the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as applicable."
According to the Mayo Clinic (© 1998-2016 Mayo Foundation for Medical Education and Research) Male infertility is defined as:
“A male's inability to cause pregnancy in a fertile female in light of unprotected sexual intercourse for a year or longer.”
There are many varied treatments for fertility issues. However, the root cause of the infertility will drive what options are utilized. In women, infertility may be caused by ovary dysfunction, blocked or damaged fallopian tubes, uterine disease processes such as fibroid tumors or endometriosis, cervix stenosis, endocrine hormone dysfunction and in some cases, stress and/or medication side effects. It has been noted in some studies that up to 15% of infertility cases, the actual cause may remain unexplained. In men, infertility may be caused by obstruction of the testes, epididymis, vas deferens, ejaculatory duct, distal seminal ducts, varicocele, hypogonadism, cryptorchidism, reproductive gland infections, ejaculatory disorders, or hormonal deficiencies with testosterone or endocrine malfunction.
Female infertility can be treated in several ways, including:
• Laparoscopy: This is usage of a surgical technique using a laparoscope to remove any scar tissue, endometriosis, ovarian cysts or open/re-open blocked fallopian tubes.
• Hysteroscopy: Is usage of a hysteroscope, placed into the uterus which can be used to remove polyps, fibroid tumors, endometriosis, scar tissue, open/re-open blocked fallopian tubes.
• Medical therapy: (Drug therapy for ovulation problems) Medications prescribed such as clompiphene citrate (Clomid, Serophene), letrozole, or gonadotropins can help induce ovulation, Other drugs such as Metformin (glucophage) may be prescribed for women who have insulin resistance, or PCOS (Polycystic Ovarian Syndrom)
• Intrauterine sperm insemination: ISI refers to an office based procedure where semen is collected, rinsed with a special solution, and then placed into the uterus at the time of ovulation.
• In vitro fertilization: IVF refers to a procedure in which eggs are fertilized in a culture dish and placed into the uterus.)
•Intracytoplasmic Sperm Introduction: ICSI is a procedure where sperm is injected directly into the egg in a culture dish and then placed into the woman’s uterus
• GIFT (Gamete intrafallopian tube transfer)/ ZIFT (zygote intrafallopian transfer): These procedures are similar to IVF. Both procedures involve retrieving an egg combining with sperm then transplanting back into the uterus. (In ZIFT, the fertilized eggs -- at this stage called zygotes -- are placed in the fallopian tubes within 24 hours. In GIFT, the sperm and eggs are mixed together before being inserted.)
• Egg donation: The egg donation procedure involves the removal of eggs from the ovary of a donor, then placed mixed with the sperm from the recipient's partner and transplanted into the uterus via the IVF procedure.
In men there are fewer procedural options for infertility
- Microsurgical Epididymal Sperm Aspiration (MESA) or Testicular Sperm Extraction (TESE): In men, if the semen sample(s) contain no spermatozoa due to a congenital obstruction of the sperm ducts, vasectomy, failed vasectomy reversal or primary testicular failure. A patient can have the physician retrieve sperm surgically from the epididymis (MESA) or from the testis (TESE). Once the retrieval is performed, the sperm can then be frozen and/or used for fertilization by the ICSI method.
- Varicocelectomy: This is procedure in which a cluster of varicose veins around the vas are removed or tied off. Urologists have stated that there is a possibility that due to increased blood circulation around these veins, it is thought to increase testicular temperature and reduce sperm production.
- Testicular biopsy: This is a procedure in which small portion of tissue is removed from both testicles and sent for histological laboratory examination. If there is a zero sperm count and the testicles are of normal size, the cause may be an obstruction to sperm outflow or a failure of the testicles to produce sperm. If the biopsy will determine if there are sperm in normal numbers, or show a zero sperm count, in which it is more likely due to an obstruction.
ICD-10cm code set guidelines
In ICD-10cm the N97 codes represent the diagnosis of female infertility, and it “excludes” those codes associate with hypopituitarism (E23.0) and Stein-Leventhal Syndrome (E28.0) both of which are found in chapter 4 which contains the codes for endocrine, nutritional and metabolic diseases, rather than those in chapter 14 which are diseases of the genitourinary system. When assigning an infertility code as a patients’ diagnosis, make sure that the physician has clearly denoted that the patient truly is “infertile” and documented this diagnosis as such. If however, the physician has documented that a patient has other symptoms that could be construed as “infertility” it is important that you, as the coder, do not make the inference that the patient is diagnosed with infertility.
There are many diagnoses that may mimic infertility, or contribute to an infertile state, such as salpingitis, oophoritis, metritis, myometritis, pyometra, uterine abscess, pelvic peritonitis, pelvic abscess, endometriosis, and a host of many other diagnoses that may play a part in a patients ultimate diagnosis of infertility. However, if the physician only mentions that the patient may be infertile due to one of the above, then ask your provider to denote if the patient has primary infertility due to a specific disease process, or if the patient has a secondary infertility due to a specific disease process. Clarity and transparency of the diagnosis is critical for coding accuracy. The same theory holds true for men. It is imperative for the provider to be very specific when coding an infertility diagnosis, or coding a “symptom” or other “disease process” as the primary diagnosis. If this is the case, then the infertility code would be a secondary code on your claim.
ICD-10cm code set for female infertility:
N97 Female infertility
Includes: inability to achieve a pregnancy, sterility, female NOS
Excludes1: female infertility associated with: hypopituitarism (E23.0) Stein-Leventhal syndrome (E28.2)
Excludes2: incompetence of cervix uteri (N88.3)
- Female infertility associated with anovulation
- Female infertility of tubal origin
- Female infertility associated with congenital anomaly of tube
- Female infertility due to tubal block
- Female infertility due to tubal occlusion
- Female infertility due to tubal stenosis
- Female infertility of uterine origin
- Female infertility associated with congenital anomaly of uterus
- Female infertility due to non-implantation of ovum
- Female infertility of other origin
- Female infertility, unspecified
ICD-10cm code set for male infertility is found within the chapter 14 “N” codes too. Male infertility is represented with the codes of N46 and excludes the code Z98.52 which represents a vasectomy status.
- N46 Male Infertility
- N46.0: Azoospermia
- N46.01: Organic azoospermia
- N46.02: Azoospermia due to extratesticular causes
- N46.021: Azoospermia due to drug therapy
- N46.022: Azoospermia due to infection
- N46.023: Azoospermia due to obstruction of efferent ducts
- N46.024: Azoospermia due to radiation
- N46.025: Azoospermia due to systemic disease
- N46.029: Azoospermia due to other extratesticular causes
- N46.1: Oligospermia
- N46.11: Organic oligospermia
- N46.12: Oligospermia due to extratesticular causes
- N46.121: Oligospermia due to drug therapy
- N46.122: Oligospermia due to infection
- N46.123: Oligospermia due to obstruction of efferent ducts
- N46.124: Oligospermia due to radiation
- N46.125: Oligospermia due to systemic disease
- N46.129: Oligospermia due to other extratesticular causes
- N46.8: Other male infertility
- N46.9: Male infertility, unspecified
CPT procedures associate with infertility
Below is a table with the most common CPT procedures that are used for treatment of infertility. This includes procedures for both men and women. I have also included a table that shows many of the lab procedures that can be performed for infertility. If you code and submit claims with HCPCS there is also a table for the HCPCS codes.
Fine needle aspiration; without imaging guidance
Fine needle aspiration; with imaging guidance
Biopsy of the testis, needle
Biopsy of epididymis, needle
55200 Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)
Vasovasostomy, vas vasorrhaphy
Electroejaculation (may be used in patients who are unable to produce a normal ejaculate due to spinal cord or other nervous system disorder i.e., diabetic neuropathy)
Artificial insemination; cervical
Artificial insemination; intra-uterine
Sperm washing for artificial insemination
Transcervical introduction of fallopian tube catheter for diagnosis AND/OR re-establishing patency (any method), with or without hysterosalpingographpy
Chromotubation of oviduct, including materials
Tubotubal anastomosis (Sterilization reversal)
Tubouterine implantation (Sterilization/tubal blockage tx)
Fimbrioplasty (reconstructive to restore patency of occluded fimbriae)
Salpingostomy (microsurgery to restore tubal patency)
Follicle puncture for oocyte retrieval, any method
Embryo transfer, intrauterine
Gamete, zygote or embryo intrafallopian transfer, any method
CPT Lab/Pathology tests commonly performed for infertility
Culture of oocyte(s)/embryo(s), less than 4 days
Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos (investigational)
Assisted embryo hatching, micro techniques (any method)
Oocyte identification from follicular fluid
Preparation of embryo for transfer (any method)
Sperm identification from aspirate (other than seminal fluid)
Sperm isolation; simple prep (e. g., sperm wash and swim-up) for insemination or diagnosis with semen analysis
Sperm isolation; complex prep (e. g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis.
Sperm identification from testis tissue, fresh or cryopreserved
Insemination of oocytes
Extended culture oocyte(s)/embryo(s), 4 – 7 days
Assisted oocyte fertilization, micro technique; less than or equal to 10 oocytes
Assisted oocyte fertilization, micro technique; greater than 10 oocytes
Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos
Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); greater than 5 embryos (non-covered)
Semen analysis; presence AND/OR motility of sperm including Huhner test (post coital)
Semen analysis; motility and count (not including Huhner test)
Semen analysis; volume, count, motility, and differential
Semen analysis; sperm presence and motility of sperm, if performed
Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger)
Sperm evaluation; hamster penetration test
Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)
Cryopreservation, reproductive tissue, testicular
Cryopreservation, mature oocyte(s) (investigational)
Storage, (per year); embryo(s)
Storage, (per year); sperm/semen
Storage, (per year); reproductive tissue, testicular/ovarian (investigational)
Storage, (per year); oocyte (investigational)
Thawing of cryopreserved; embryo(s)
Thawing of cryopreserved; sperm/semen, each aliquot
Thawing of cryopreserved; reproductive tissue, testicular/ovarian (investigational)
Antisperm antibodies test (immunobead)
In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development
Complete cycle, gamete intrafallopian transfer (GIFT), case rate
Complete cycle, zygote intrafallopian transfer (ZIFT), case rate
Complete in vitro fertilization cycle, NOS case rate
Frozen in vitro fertilization cycle, case rate
Incomplete cycle, treatment canceled prior to stimulation, case rate
Frozen embryo transfer procedure canceled before transfer, case rate
In vitro fertilization procedure cancelled before aspiration, case rate
In vitro fertilization procedure cancelled after aspiration, case rate
Assisted oocyte fertilization, case rate
Donor Egg cycle, incomplete, case rate
Donor services for in vitro fertilization (sperm or embryo), case rate
Procurement of donor sperm from sperm bank
Storage of previously frozen embryos
Microsurgical epididymal sperm aspiration (MESA)
Sperm procurement and cryopreservation services; initial visit
Sperm procurement and cryopreservation services; subsequent visit
Stimulated intrauterine insemination (IUI), case rate
Cryopreserved embryo transfer, case rate
Monitoring and storage of cryopreserved embryos, per 30 days
Management of ovulation induction (interpretation of diagnostic tests and studies, non-face-to-face medical management of the patient), per cycle
Coding, Billing, Medical Necessity and Insurance Plan Coverage
Correct coding is important to you, and your physicians. The ICD-10cm diagnosis and the CPT procedures need to be linked appropriately, and clearly show the “reasons” or “medical necessity” of the testing or procedures being performed. The most common denial from insurance carriers is “procedure is deemed not medically necessary”.
Coding for infertility can and is complicated, and errors are not uncommon. Coders need to clearly understand the most common codes utilized in infertility procedures and diagnosis. Best practices contact the patient and obtain prior authorization and check insurance benefits before scheduling and/or performing any major infertility procedures.
Pre-authorization and medical review have become necessary components for payment by 3rd party payers such as insurance companies. These carriers carefully review the patients’ policy, and will advise of any conditions or policy criteria that specifically addresses infertility treatments. It has become commonplace language in most insurance policies, that all medical treatment be “medically necessary” not just treatment for infertility. Unfortunately, some insurance carriers provide minimal or even no payment for infertility testing or procedures. When pre-authorizing for infertility testing, or infertility procedures be sure to carefully review and discuss the patients’ policy with the patient, and then have the appropriate ABN signed, and/or financial commitment for payment if the insurance company does deny, or if the patient does not have any 3rd party coverage at all.
If the patient does have coverage, and the claim is denied, always appeal the claim with a copy of the patients’ policy and the expectation of what the carrier should pay toward the claim. The denial code CO50, is commonly seen on infertility claim denials, and is defined as: “non-covered services because this is not deemed a ‘medical necessity’ by the payer.” If your claim is received with this CO50 claim denial, your office will need to provide the carrier additional information to support medical necessity, which is documented in the physician/provider chart notes. In addition to sending the medical documentation, you may also want to include an additional letter or appeal from the provider stating why the physician feels the procedure is medically necessary. Another area of concern, when the claim has not been reimbursed, is there may be a notation on the denial from the carrier stating the patient is not responsible for the charges.
Another denial code commonly seen with infertility claims is denial code CO96; Non-covered charge(s), or denial code CO48; This (these) procedure(s) is (are) not covered by your policy.
If the insurance carrier adjudicates the claim with a CO96, or CO48 adjudication codes, it will also notate in the remark codes if the patient is responsible for the charges. However, If you are billing a Medicare claim, it is advisable to obtain an ABN (Advance Beneficiary Notice) signed by the patient. If the patient has a private insurance carrier, have a similar document signed and on file by the patient.
Some carriers, in addition to Medicare and Medicaid, allow for usage of the modifier “GA” on the claim. The GA modifier indicates that the expected denial is for a service that is considered to be not reasonable and/or medically necessary, nor is it expected to be paid for by Medicare and/or Medicaid Services (or the private carrier). If the claim is billed to a Medicare/Medicaid carrier and the GA modifier is used, the remittance advice will notate that the patient is responsible for the charges incurred.
Operative Records/Clinical Documentation
Included below is an operative report for your review, the CPT codes are those which are actually documented within the report, however, you will note that there is a modifier 59 appended to the chromotubation code. When these codes were run through the CCI bundling edits, the 58350 was considered “bundled” with the other three codes, however, CCI states that a modifier 59 is permitted if appropriate. In this operative report, the chromotubation is performed to assess where the blockage is within the fallopian tube.
OPERATIVE REPORT #1
PREOPERATIVE DIAGNOSES: Chronic pelvic pain , endometriosis, infertility .
OPERATION PERFORMED: Operative laparoscopy, lysis of adhesions, right fimbrioplasty, tubal insufflation.
OPERATIVE INDICATIONS AND FINDINGS: 26yo G1P1 with a long history of pelvic pain and known endometriosis with a documented 24 months of infertility. She underwent an operative laparoscopy a little more than 6 months ago with findings of massive pelvic endometriomas, and endometriosis of the uterus. Multiple fulgurations were performed and cystectomies.
At time of this surgery, the pelvis is dramatically better, but there is obvious evidence immediately of active endometriosis. The bladder flap was peppered with active endometrial implants. There were implants along both lateral pelvic sidewalls. The right ovary is almost completely free. The right fallopian tube is as well. Unfortunately, at the time of tubal insufflation, the right fallopian tube fairly readily fills but never spills and there is a very thin-walled hydrosalpinx in its distal end. The left fallopian tube is adhered along with the bottom side of the ovary, which is at the same time completely adhered to the lateral pelvic sidewall. I am able to free the ovary with blunt and sharp dissection, allowing its distal end to be free. The ovary was taken down with significant more difficulty. At this time of tubal insufflation, there is no apparent filling whatsoever along and throughout the left fallopian tube, which I feel is the culprit behind patient’s infertility. However, the fallopian tube does appear normal and the fimbriated end is normal as well. I would not exclude the possibility that the left ovary could in fact be functional but would require a hysterosalpingogram to better determine that. A distal salpingostomy was performed with multiple small incisions to help simulate the fimbria. It was somewhat rudimentary, but nonetheless the left tube is free and does lie open spontaneously.
OPERATIVE PROCEDURE: The patient was placed under appropriate general anesthesia, brought to the Operating Room, identified, placed under appropriate general anesthesia, prepped and draped in the usual fashion in the low-lying dorsal lithotomy position. A Graves speculum was used to visualize the cervix and an acorn tip was placed inside the cervical canal and secured with the tenaculum for tubal insufflation. An infraumbilical incision was made. A 5 mm laparoscopic trocar and sheath was placed into the abdomen, which was insufflated with carbon dioxide under direct visualization. The left lower quadrant port was made through her previous incision and a 5 mm port with a balloon was placed similarly. After noting the above described findings, it was apparent that this second port would be necessary and a right lower quadrant 5 mm port was placed without difficulty.
First of all, the ovarian adhesions on the left side were taken down with blunt and sharp dissection from the lateral pelvic sidewall and the back side of the uterus. The right fallopian tube was taken off of the ovary. The right ovary was barely adhered down and was freed up with blunt dissection. Tubal insufflation was performed with 60 cc of saline and methylene blue to ascertain if there was tubal blockage. As described above, the right fallopian tube filled but never spilled. The left fallopian tube did not fill or spill, although the appearance of the left fallopian tube was normal. Once the tubal insufflation was accomplished, the acorn tip was removed and a Hulka manipulator was placed for better manipulation in the uterus. Endometrial implants throughout the bladder sidewall and cul-de-sac were individually cauterized with the monopolar hook cautery. The patient has a large window in the right side of the cul-de-sac. There are multiple endometrial implants within it. Cautery was used to fulgurate around the edge of the window shrinking it to about a third of its original size.
The right fallopian tube was grasped near its hydrosalpinx and at this point ultimate fusion was identified and using monopolar cautery and scissors. A small stab wound was made and then the stellate incisions were made from there by both sharp dissection and a little bit of cautery to control bleeding until the distal end of the right fallopian tube lay free. At this time, the blue dye readily spilled from the right fallopian tube. The remainder of the implants on the left side underneath where the ovary was adhered, were fulgurated. Once this was accomplished, the pelvis was thoroughly irrigated with about 800 cc of Lactated Ringers. The pelvis was suctioned free and about 2 g of Arista was placed in the lateral pelvic side wall, mostly behind the left ovary to minimize adhesion formation. The ports were removed and the CO2 was expelled. The wounds were closed with 4-0 Vicryl sutures, dressed with 2 x 2's and Opsites. The patient was awakened and taken to the Recovery Room in good condition. The estimated blood loss was less than 10 cc. None was replaced.
CPT Procedure Codes
- 58672 Laparoscopic Fimbrioplasty
- 58673-51 Laparoscopic Salpingostomy
- 58662-51 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
- 58350-59-51 Chromotubation of oviduct
ICD-10cm Diagnosis Codes :
- R10.2 Pelvic and perineal pain
- N97.1 Female infertility of tubal origin
- N80.3 Endometriosis of pelvic peritoneum
- N80.8 Other endometriosis (bladder sidewall
- N73.6 Female pelvic peritoneal adhesions (postinfective)
Operative Report #2
OPERATIVE REPORT: Bilateral vasovasostomy
OPERATIVE DX: Male Infertility due to vas blockage, inflammation w/ chronic vas pain
OPERATION PERFORMED: Operative vasovasostomy - bilateral
A small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens. Methelyene blue dye was then injected within the tube denoting the exact area of blockage. Next the incision was carried down to the area of the inflammation and noted blockage/scarring with complete occlusion of the vas deferens. A towel clip was placed around this. The scarred area was dissected free back to normal vas proximally and distally. Approximately 4 cm of vas was freed up. Next the right vas was amputated above and below the scar tissue. Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends. Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully. After accomplishing this, fluid could be milked from the proximal right vas which was encouraging.
Next the re-anastomosis was performed. Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen. This was all done with 3.5 loupe magnification. Next the right vas ends were pulled together by tying the sutures. A good re-approximation was noted. Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight. Upon the re-anastomosis, methelyne blue dye was again inserted into the tube with no blockages noted.
There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum. The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.
Next an identical procedure was done on the left side, however, only a partial blockage noted with minimal dye within the tube. The area of blockage on the left was noted, and excised in the same manner as the right.
The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition. Antibiotic ointment, fluffs, and a scrotal support were placed.
CPT Procedure Codes
- 55400-50 Vasovasostomy, vasovasorrhaphy (Mod 50 is appended, as this procedure was performed bilaterally)
ICD-10cm Diagnosis Codes :
- N46.023 Azoospermia due to obstruction of efferent ducts
- R10.2 Pelvic and perineal pain
- N49.1 Inflammatory disorders of spermatic cord, tunica vaginalis and vas deferens
Coding Wrap Up
As a coder, having good documentation provided to you from your providers, and noted in the medical record ensures that you are able to clearly code and report the operative session(s), with the diagnosis of infertility and all additional diagnoses that are noted in addition to infertility. All of these criteria go hand in hand with good quality patient care and correct coding and billing of claims. By working closely with your providers, you can ensure good clean claims, and reduce your overall risk of audit inquiry and financial recoupment of paid claim services. Always maintain diligence in performing pre-authorization and a targeted reviews of the patients’ insurance policy in regard to infertility testing and procedural correction prior to services being rendered by your physicians. If the carriers do issue denial, review the denial and take appropriate action such as appeals, and or collection of fees from the patient.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at email@example.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.