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ECUGirl2004
member
Insurance coding of IF diagnostics (HSG, lap, etc) ?
ECUGirl2004
member
I'm curious about how things get coded in the IF world for diagnostics and treatments. When do you cross the line between seeing a specialist for cycle issues to seeing a specialist for infertility?
My insurance has a limit of $2500 per year for anything infertility related, as far as I can tell (though it might just be a limit on surgery stuff... I'm checking with HR on that one).
So what I'm wondering is, if I have to have a laparoscopic surgery to determine if I have endometriosis, does that get coded as an IF diagnostic/treatment? Or could it be just a general surgery? It seems like the line there is very fuzzy. Shouldn't endo be diagnosed and treated regardless of whether I'm TTC? Or is the fact that I'm TTC the key point that determines that it's IF related?
Does that make any sense at all? I'm just trying to understand what I can expect insurance to cover and how I'll need to time things if I end up having to have the lap done.
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Re: Insurance coding of IF diagnostics (HSG, lap, etc) ?
Our Thanksgiving Day baby 11/22/07
Pregnant with #2 with LPD, uterine polyp/hysteroscopy, DOR (AMH = 0.17), 2 c/ps
Our early Christmas present 12/9/10
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It is tough, and even HR and the insurance companies can give you vague information. What worked best for me was to just straight up talk to my OB/RE about it. They know how to work the codes in your favor. I would think anything endo related could be coded so that it didn't count towards your IF amount. That's something that should be diagnosed and treated regardless of whether or not you're TTC.
My insurance didn't cover IF at all, and we managed to not have to pay anything extra. DH's SA, my Femara, tests, etc were all covered. I did not have an HSG though, so I'm not sure where that would fall.
He also did the same during my pg to make sure extra u/s I needed would be covered.
Definitely speak with your Dr and their billing specialist before you book anything, they need to understand your insurance coverage and needs so that it's done properly. In some cases, it is what it is. In other cases, the code can/will make all the difference.
You are right that endo is an issue, ttc or not. Hopefully insurance agrees.
I dealt with an ob/gyn in the beginning of my IF process because I didn't realize what I was doing. I highly suggest working with an RE as soon as possible. At least meeting with them for a consult, even if you decide to have certain tests and procedures performed by an ob/gyn. I spent almost a year getting treatment, 5 mths of that with an ob/gyn. I know that without a doubt that my road would have been much easier (and safer) and therefore less expensive if I had gone to an RE from the beginning.
I went to Carolina Conceptions. I loved all of the Drs there, but I was assigned to Dr Park. It's a wonderful practise and they bend over backwards to work with patients, including billing issues.
Good luck! Sometimes a good cleanout with an hsg and lap is all it takes, I hope that's the case for you.
LO#1 - 19 cycles, 3 IUIs, 1 m/c, gonal-f, ganirelix, ovidrel, progesterone
Totally worth the wait!
Getting ready for #2
Back on Met, PCOS diet, prepping for treatments 1/12
Good luck to the wonderful ladies of 3T
Always cheering on my girls Gymnst1013 & MrsJohns
My Chart / Info for Newbies
Katie, Duke Gardens, 6months
Zach, Duke Gardens, 6months
Photo courtesy from the amazing Ever You Photography!
Oh, I understand 100%!!! I've been there!!!
IME, all cycle-specific monitoring was IF (u/s and b/w), HSG was IF, etc. However, with Kira everything that could be coded as PCOS was, and this time everything that could be coded as uterine polyp was, which covered my surgery. I think the ultrasounds were my biggest obstacle, and unfortunately most had to be coded as IF, even though I fought it.
Our Thanksgiving Day baby 11/22/07
Pregnant with #2 with LPD, uterine polyp/hysteroscopy, DOR (AMH = 0.17), 2 c/ps
Our early Christmas present 12/9/10
https://forums.fertilitycommunity.com/primary-infertility/206022-hsg-cost.html
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58340 & 74740 would be reported.
CPT 58340 only includes the catheterization and intro. of saline/contrast while 74740 captures the radiological supervision & interpretation related to the HSG.
Both the surgical component & the S&I have notes that point towards the other component of the procedure...
i.e.
58340 Catheterization and introduction of saline....
(For radiological S&I of HSG, use 74740)
74740 Hysterosalpingography, radiological S&I...
(For intro. of saline/contrast for HSG, see 58340)
There are CPT Assistants that address the components of HSG.
Katie, Duke Gardens, 6months
Zach, Duke Gardens, 6months
Photo courtesy from the amazing Ever You Photography!
This gives hope. Do you have any of these? https://www.advancedfertility.com/hsg.htm
What else can be seen with a hysterosalpingogram, besides whether the tubes are open?
Other things that can be seen on a hysterosalpingogram aside from whether the tubes are open or blocked include:
Katie, Duke Gardens, 6months
Zach, Duke Gardens, 6months
Photo courtesy from the amazing Ever You Photography!
Well, the whole story for me is that I have mid-cycle spotting. It's pretty heavy and it definitely falls within the abnormal bleeding range. We also think that the spotting is so heavy that it would prevent pregnancy. We're doing the HSG to see if there are fibroids, polyps or anything else that could cause bleeding. If the HSG is clear, we'll discuss whether I should have laparoscopic surgery to see if I have endometriosis.
Since my insurance limits my IF coverage to $2500/year, I want to be sure that if things can be coded for something other than IF, they are. I don't want to find out that we need IUI and then not have any insurance coverage for it.
I'm very thankful we're at the end of the year though.... at least that $2500 starts over again on Jan 1.
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Lee, I'm not sure if the $2500 includes diagnostics or not. I emailed my HR department today to find out. The way it is explained in our benefits manual is confusing to me. Here's what it says:
Coverage will be provided for the following services:
?? Testing and treatment services performed in connection with an underlying medical condition.
?? Testing performed specifically to determine the cause of infertility.
?? Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility
condition).
?? Artificial Insemination
Surgical Treatment: Limited to procedures for the correction of infertility (excludes In-vitro, GIFT, ZIFT, and other
Implant procedures.)
Note: Maximum: $2,500 per year.
What do you think? Oh, and thanks for offering to look in the code book. If it comes to that, I'll definitely hit you up for some advice.
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First of all, I know it may not seem like much to you, but that's GREAT infertility treatment! Seriously.
Secondly, I worked w/ my RE and their awesome financial people to make sure anything that could be coded as Ob/Gyn vs. IF was. That helped quite a bit. My HSG was covered except for copay & like 15%, but we had it done 2 days before we switched insurance. I doubt our new ins. would cover it at all.
Are you seeing an RE for your HSG or your regular doctor?
Alethea - I'm seeing an RE at UNC. I am really grateful that I have some infertility coverage, believe me! I just want to make sure that I am able to make the most out of it, you know?
MrsLee - I hope so! HR should get back to me within the next day or two, so I'll have an answer then.
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