Billing Infertility Claims? Focusing on These Types of Codes Can Help
Learn how to code infertility claims accurately by focusing on symptoms, consultations, and specific diagnoses to ensure proper reimbursement and avoid claim denials.
OB/GYN Medical Billing & Coding Alert
When it comes to billing for infertility-related services, it's essential to proceed with caution, mainly when coding for infertility diagnoses such as N97.9 (Female infertility, unspecified).
According to the Centers for Disease Control and Prevention (CDC), approximately 19 percent of married women aged 15 to 49 years with no prior pregnancies experience difficulty in conceiving after one year of trying.
As a result, infertility often becomes a primary concern in many claims. However, focusing on symptoms rather than simply using the code N97.9 can significantly improve how payers view and process your claims.
The term "infertility" itself can pose challenges for reimbursement. Many insurance carriers do not cover infertility treatments unless mandated by specific state laws, with only 18 states in the U.S. requiring infertility treatments to be covered (you can check the details at Health Insurance FAQs). As a result, many payers may hesitate or refuse coverage when the term "infertility" is used in the claim.
Infertility-related services require a thorough review before the patient's visit. It's important to verify insurance coverage or the lack thereof and communicate this with the patient, ensuring a clear understanding of who pays for the services.
To maximize ethical reimbursement and minimize claim rejections, focus on more specific diagnostic codes highlighting the symptoms rather than simply identifying the condition as infertility.
Furthermore, always confirm insurance coverage and discuss it with patients upfront to prevent confusion or unexpected costs.
Step 1: Focus on the Presenting Symptoms
When a patient presents for an initial "infertility" visit, it's essential to understand that the visit may not necessarily be about infertility itself. In most cases, the cause of infertility is not immediately apparent. Instead, the patient typically presents with a symptom or complaint, which should be identified as the primary reason for the visit.
Why Infertility May Not Be the Primary Focus?
The primary diagnosis should focus on the symptoms or concerns that prompted the visit. If the OBGYN addresses and treats the patient's presenting symptoms, infertility may never become the central issue. It's crucial to guide physicians to document specific diagnoses and clearly define the reason for the encounter, whether it's a symptom, problem, or complaint.
Key Point: You should only report confirmed diagnoses—diagnoses based on suspicion alone cannot be coded.
Example: Pelvic Pain and Infertility Concerns
Consider a patient presenting with pelvic pain (R10.2, Pelvic and perineal pain). During the visit, the patient mentions her difficulty in conceiving over the past year. While infertility is discussed, the OBGYN's primary focus is to diagnose and treat the pelvic pain. The infertility discussion is secondary, and the appropriate primary diagnosis for this visit is R10.2 (pelvic pain).
Upon further testing, the OBGYN discovers that the patient has endometriosis (N80.0-). The treatment plan includes surgery, and for subsequent visits, the N80.0- code should reflect the severity of the condition as the primary diagnosis. Many women will conceive after successful treatment of endometriosis, and infertility might not be a factor at all.
When Infertility Becomes a Secondary Concern
Once the OBGYN successfully treats the underlying condition like endometriosis, fertility may no longer be a concern. In these cases, infertility might only need to be documented as a secondary diagnosis if it's relevant. However, if infertility is the primary reason for the visit, you may face higher chances of a denial.
Be Cautious About Fertility Discussions
It's essential to recognize that OBGYNs often discuss pregnancy and fertility as part of the patient's history during the first visit. Just because fertility is part of the conversation doesn't mean the physician is treating infertility. If the physician focuses on diagnosing and treating another symptom (such as pelvic pain), then that symptom should be reported as the primary diagnosis, not infertility. Don't let payers challenge your coding based on the inclusion of fertility discussions—ensure the documented symptoms take priority.
Step 2: Avoid Overlooking Consultations
When coding for an initial infertility visit, you might be tempted to classify it as a standard office visit. However, this may not always be the correct choice. Often, a woman's primary-care physician will refer her to the OB-GYN for further evaluation. In such cases, you can bill for a consultation (99242-99245), provided the payer covers consultations and the OB-GYN documents the necessary components. An explicit request for an opinion or advice from the primary care physician is also required.
Understanding the "Five R's" of a Consultation
For the visit to qualify as a consultation, five key components must be met:
- Reason: The primary physician must specify the reason for the consultation.
- Request: The primary physician must formally request the OB-GYN's opinion or advice.
- Render: The OB-GYN must examine and evaluate the patient's condition.
- Report: The OB-GYN must report the findings to the primary physician after the consultation.
- Return: The OB-GYN must return the patient to the primary physician for continued care.
Ensuring these components are correctly documented allows the consultation to be billed appropriately, allowing you to get reimbursed for the service.
Example: Consultation for Irregular Menses and Cystic Acne
Consider a patient who presents to your OBGYN with irregular menses (N92.6) and cystic acne (L70.0) at the request of her primary-care physician. The primary physician suspects ovulatory dysfunction or polycystic ovarian syndrome (PCOS) and requests the OB-GYN's opinion. After conducting a detailed history, exam, and diagnostic testing, the OB-GYN diagnoses the patient with PCOS (E28.2), with infertility only being discussed as a secondary symptom. The OB-GYN then reports the findings and proposed treatment plan to the primary care physician.
Solution: Proper Coding for Consultation
In this scenario, the OBGYN should report a consultation (99242-99245) based on the level of service provided. The corresponding diagnoses should include N92.6 (Irregular menstruation), L70.0 (Acne vulgaris), and E28.2 (Polycystic ovarian syndrome).
Important Reminder: Avoid Overuse of Infertility Codes
It's crucial not to use the infertility diagnosis code (such as E28.2) alone, as many carriers may associate this with infertility treatments and could deny payment for the consultation.
Rule of Thumb: Determine if Infertility is Primary or Secondary
Ultimately, whether infertility is primary or secondary to another diagnosis will determine how the claim is processed. Even if infertility is the primary concern, some payers may still cover the first or second visit or any service that helps determine the cause of infertility. It's essential to substantiate whether infertility is the primary issue, as this will affect reimbursement.
Why BillingFreedom is the Best Choice for OB-GYN Medical Billing?
BillingFreedom is the best choice for an ob/gyn billing service due to its expertise in handling complex claims, such as infertility-related services. The platform ensures accurate coding by focusing on specific symptoms rather than generic diagnoses, reducing claim rejections and denials.
BillingFreedom’s thorough approach includes verifying insurance coverage, advising patients on financial responsibilities, and ensuring precise consultation documentation.
By adhering to proper coding standards, including the “five R’s” for consultations, and correctly identifying primary and secondary diagnoses, BillingFreedom maximizes reimbursement while minimizing errors, making it a trusted partner in medical billing.
For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472.
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