Infertility Consult

Does ASRM have any examples of evaluation and management documentation for patients being seen for an initial infertility evaluation? I am trying to give examples of how providers can document level 4 or 5 new patient visit when being seen for infertility. Not sure how a provider can get 4 HPI elements, complete ROS and comprehensive physical examination when a patient is seen for infertility. If a 36 year old seen for secondary infertility. Trying to get pregnant for three years with un-protective intercourse. Example: Infertility=location, Secondary=context, and three years=duration, un-protective intercourse=modifying factors. Would complete ROS and comprehensive physical examination be medical necessary for “infertility” for a patient with no preexisting problems? My provider wants to bill the level 4 and 5 visits, but does not want to document time.


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