Infertility is defined as not being able to achieve pregnancy after regular, unprotected intercourse for at least a year. In the United States, about 12 to 13 couples out of 100 have trouble conceiving, according to the Department of Health and Human Services (HHS). In vitro fertilization (IVF), the most common type of assisted reproductive technology (ART), enables many couples for whom other infertility treatments have not worked, achieve a pregnancy. Over the years, the codes to report diagnoses and treatments have increased along with the variety and complexity of ART. Gynecologists and fertility specialists can accurately report their work and the diagnoses that justifies it using infertility billing and coding services.

Complete and accurate documentation of all procedures is crucial for an efficient reproductive endocrinology billing process. Moreover, accurate claims submission also hinges to a large extent on being knowledgeable about insurance since coverage for IVF varies widely among insurance plans. Insurance verification services can ease this challenge.

Causes of Infertility

Many factors can prevent spontaneous union of the sperm and the egg. Infertility causes may exist from birth or develop later and may be present in one partner or in both. Ovulation problems and blocked fallopian tubes are the most common reasons for infertility in women. Additional causes include: uterine or cervical abnormalities, endometriosis, early menopause, pelvic adhesions, and certain cancers and their treatments. Causes of male infertility include abnormal sperm production or function, issues related to sperm delivery, infection, injury, exposure to toxins, chromosomal abnormalities, systemic diseases. Other risk factors may include smoking, alcohol use, obesity, and older age.

Treatments for infertility range from simple interventions such as fertility drugs to induce ovulation to more complicated options such as artificial insemination or IUI sperm injections and in vitro fertilisation (IVF).

IVF: What is it and When is it Considered?

IVF is a method of assisted reproduction in which mature eggs are extracted from a woman’s ovaries and manually combined with a man’s sperm in a laboratory dish. The fertilized egg or embryo is later placed into the uterus. The IVF process involves the following complex steps:

  • Ovarian stimulation – medications or fertility drugs are given to stimulate multiple eggs to grow in the ovaries
  • Egg retrieval – this is usually done through a minor surgical procedure known as transvaginal ultrasound aspiration or using laproscopy
  • Fertilization and Embryo Culture – The retrieved eggs are evaluated for maturity and quality. Sperm is added to selected mature eggs for the embryos to develop.
  • Embryo transfer – One embryo or more embryos are placed in the uterus. The number of embryos transferred is based on the patient’s age and other individual patient and embryo characteristics. Care is taken to reduce the risk of high-order multiple gestation.

ART procedures can be performed using donor eggs, donor sperm, or previously frozen embryos.

Couples consider IVF when other infertility treatments do not work. However, for women over age 40, IVF may be offered as a primary treatment for infertility. IVF may be an option for couples who have one or more of the following, according to Mayo Clinic:

  • Fallopian tube damage or blockage
  • Ovulation disorders
  • Endometriosis
  • Uterine fibroids
  • Previous tubal sterilization or removal
  • Impaired sperm production or function
  • Unexplained infertility
  • A genetic disorder
  • Fertility preservation for cancer or other health conditions

IVF ICD-10 and CPT Codes

ICD-10 codes for ART procedures

Infertility diagnosis codes should be as specific as possible. While some main codes cannot be used for billing purposes, their sub-codes may be billable. The ICD-10 codes for reporting infertility diagnosis are as follows:

  • E23.0 Hypopituitarism
  • N46.01 Organic azoospermia
  • 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
  • N46.11 Organic oligospermia
  • 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
  • N97.0 Female infertility associated with an ovulation
  • N97.1 Female infertility of tubal origin
  • N97.2 Female infertility of uterine origin
  • N97.8 Female infertility of other origin
  • N97.9 Female infertility, unspecified
  • N98.1 Hyperstimulation of ovaries

IVF CPT Codes

Correctly coding fertility treatment depends on proper use individual and specific CPT codes for each component of the laboratory processes involved in an IVF cycle. Typically, procedures involving the embryo are coded for the female partner, while those directly involving sperm alone are coded for the male partner. On the other hand, both these sets of procedures may be applied to the female (www.fertstert.org/article). The CPT codes applicable to the IVF cycle are as follows:

  • 58970 Follicle Puncture for Oocyte retrieval, any Method (IVF)
  • 89250 Culture of oocyte(s)/embryo(s), less than 4 days
  • 89251 Culture of oocyte(s)/Embryo(s), less than 4 days; with co-culture of oocyte(s)/embryo(s)
  • 89253 Assisted embryo hatching, microtechniques(any method)
  • 89254 Oocyte identification from follicular fluid
  • 89255 Preparation of embryo for transfer (anymethod)
  • 89257 Sperm identification from aspiration (otherthan seminal fluid)
  • 89258 Cryopreservation; embryo(s)
  • 89259 Cryopreservation; sperm
  • 89260 Sperm isolation; simple prep (e.g., spermwash and swim-up) for insemination or diagnosiswith semen analysis
  • 89261 Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient for insemination or diagnosis with semen analysis
  • 89264 Sperm identification from testis tissue,fresh or cryopreserved
  • 89268 Insemination of oocytes
  • 89272 Extended culture of oocyte(s)/embryo(s),4–7 days
  • 89280 Assisted oocyte fertilization,microtechnique; less than or equal to 10 oocytes
  • 89281; Greater than 10 oocytes
  • 89290 Biopsy, oocyte polar body or embryoblastomere, microtechnique (for preimplantationgenetic diagnosis); less than or equal to 5embryos
  • 89291; Greater than 5 embryos
  • 89335 Cryopreservation, reproductive tissue, testicular
  • 89337 Cryopreservation, mature oocyte(s)
  • 89342 Storage, (per year) for embryo(s)
  • 89343 Storage, (per year) for sperm/semen
  • 89344 Storage, (per year) for reproductive tissue, testicular/ovarian
  • 89346 Storage, (per year) for oocyte(s)
  • 89352 Thawing of cryopreserved; embryo(s)
  • 89353 Thawing of cryopreserved; sperm/semen, each aliquot
  • 89354 Reproductive tissue, testicular/ovarian
  • 89356 Thawing of cryopreserved; oocytes, each aliquot

HCPCS Codes

  • S4011 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
  • S4015 Complete in vitro fertilization cycle, not otherwise specified, case rate
  • S4016 Frozen in vitro fertilization cycle, case rate
  • S4017 Incomplete cycle, treatment canceled prior to stimulation, case rate
  • S4018 Frozen embryo transfer procedure canceled before transfer, case rate
  • S4020 In vitro fertilization procedure canceled before aspiration, case rate
  • S4021 In vitro fertilization procedure canceled after aspiration, case rate
  • S4022 Assisted oocyte fertilization, case rate
  • S4023 Donor egg cycle, incomplete, case rate
  • S4025 Donor services for in vitro fertilization (sperm or embryo), case rate
  • S4026 Procurement of donor sperm from sperm bank
  • S4028 Microsurgical epididymal sperm aspiration (MESA)
  • S4037 Cryopreserved embryo transfer, case rate

Health Insurance for IVF Treatment

Understanding health insurance that covers infertility treatments can be challenging. When it comes to coverage for IVF treatment, health plans have varying rules. Some plans do not cover IVF. Some plans cover both IVF as well as the injections associated with the treatment. Other plans cover IVF, but may not cover the injections. While providers document services correctly, the submission of a code does not guarantee reimbursement. Other policies and coverage determination guidelines may apply to the member’s plan.

Candidates for infertility care are not automatically eligible for services covered by their plan. Insurance plans may require certain pre-treatment processes for fertility services. Many insurers require prior authorization for all fertility treatments.

Both patients and providers can benefit from insurance verification and prior authorization support. An insurance verification specialist will:

  • Contact the insurance company to determine candidate’s plan requirements and benefits available soon after the initial consultation with the gynecologist
  • Determine if diagnostic testing is covered
  • Confirm whether the candidate’s infertility treatment coverage includes coverage for in vitro fertilization, intracytoplasmic sperm injections (ICSI) and cryopreservation (freezing of embryos or sperm) or egg donor treatment
  • Whether precertification is required for infertility treatment
  • Deductible/co-pay/co-insurance for infertility related charges

Medical billing companies with expertise in infertility and reproductive endocrinology medical billing and coding can help gynecology practices overcome all these coding and claim submission challenges. This will allow providers to focus on helping patients overcome their fertility challenges.