Correct coding is important for you—the IVF patient—as well as your medical providers and their accounting staff. While ICD-9 codes relate to diagnoses, CPT codes denote specific procedures. In order not to receive a denial on a health insurance claim, the CPT codes entered on each insurance claim must correctly correspond to the ICD-9 codes. Clinicians and billing staff sometimes make errors in coding, and a health insurance claim may be denied simply on that basis. The stated reason by the insurer for denial of payment is often that the procedure was “not medically necessary”. If you think you have gotten one or more claims denied by one of these errors your should contest them.
For in vitro fertilization, the coding can get especially complicated, and errors are not uncommon. Therefore, understanding the most common codes utilized in IVF health insurance can enable you to check if a claim denial was based on a coding error—and notify your clinic to re-submit the claim. According to an article in the Journal of the American College of Radiology, physicians correctly coded only 42% of interventional radiology patients. In a 2010 article by Skelly and Bergus, they found that family physicians’ frequently under-coded their visits as well as made errors in CPT coding.
Some infertility-related ICD-9 codes (as of 2012) include:
- 628.0 = female infertility, associated with anovulation
- 628.2 = female infertility of tubal origin (e.g., fallopian tube blockage)
- 256.4 = polycystic ovaries
- 752.19 = other anomalies of fallopian tubes and broad ligaments
- 617.1 = endometriosis of the ovary
- 617.2 = endometriosis of the fallopian tube
Typical CPT codes related to IUI and IVF include:
- 58322 = insemination
- 58974 = intra-uterine embryo transfer
- 58970 = oocyte (egg) retrieval
- 89280 = intra-cytoplasmic sperm injection
While ICD-9 coding can be exasperating and labor-intensive—especially for clinicians—it serves an important purpose in medical and healthcare research as well as governmental rate-setting departments. For public health researchers, the ICD-9 codes in electronic medical records can provide an indication of changes in the prevalence of specific health conditions (e.g., pediatric asthma, pediatric Type 2 diabetes, and HIV ). By searching on specific ICD-9 codes, researchers can acquire data to gain a better sense of emerging trends in health conditions. The relationship of IVF to multiple births was acquired in part as a result of research utilizing codes in medical records.
On the other hand, the complexity of coding presents an administrative challenge to reproductive health clinics requiring a sizable billing staff—and may be a factor in the increased costs passed on to patients.
Many insurance companies include nurse case managers as essential staff whose primary role is to review and seek ways to deny claims. The inclusion in most health insurance policies of a clause specifying that treatment be “medically necessary” provides a convenient loophole to deny treatment—especially high-cost treatment. Even those insurance companies that cover in vitro fertilization are focused on finding ways to deny claims to reduce their expenses. By maintaining narrow parameters for CPT codes to correspond to ICD-9 codes, they can limit their coverage. Therefore, your diagnosis as entered in ICD-9 codes is very important in terms of payment by insurers for procedures and tests by your clinicians.
Being aware of the implications of coding on the actual costs covered by your health insurance plan can enable you to ensure that you are not being short-changed in the claims approval process. After all, IVF is expensive enough without receiving a bill from your clinic for something your insurance should have covered.