IVF cycle management and facility fees, an overview
1. How should IVF Cycle Management be coded? Specifically, this is for the care needed for each IVF cycle, to review, discuss the treatment plan and phone calls made to physicians, nurses, and pharmacies. 2. How should IVF Facility Fees be coded? Specifically, for the cost of use of supplies, in office surgical procedures to maintain the surgical facility. This would be for facility costs of the outpatient procedures including IVF retrieval and embryo transfer.
IVF cycle management refers to the care needed for each IVF cycle to review, discuss the treatment plan and phone calls made to physicians, nurses, and pharmacies. There is no specific code for cycle management, so many programs do not charge for this service. Some have used 99499, which is for unlisted E+M services; however, third-party payors are not likely to reimburse for this code.
Monitoring E&M
Evaluation and Management (E/M) services on the same day as office procedures should be reported only if the patient’s condition requires a significant, separately identifiable evaluation and management service. That E/M service should be above and beyond the usual pre- and post-procedural care. If the patient was evaluated by the nurse or physician on the same day as the venipuncture and/or ultrasound, and the E/M visit was appropriately documented, then the appropriate E&M service may be coded (with a -25 modifier on the E&M service). Likewise, if the patient comes back and sees the physician or nurse at a later time for discussion of the results of the test, the appropriate level of E&M may also be documented and coded on that date of service. Routine use of E/M codes with every follicular monitoring scan is not advised as there needs to be a medical necessity for the E/M service that was separately identifiable from the process of follicle monitoring.
Limited monitoring ultrasound CPT
The code for a comprehensive transvaginal pelvic ultrasound (76830) includes imaging of the uterus, fallopian tubes, ovaries and pelvic structures, as indicated. A follow-up ultrasound, whether the approach is transvaginal or transabdominal, is coded as 76857. This code describes a focused examination limited to the assessment of one or more elements, or re-evaluation of one or more pelvic abnormalities, previously demonstrated on ultrasound. This is the appropriate code for follicular monitoring and for a limited follow-up transvaginal ultrasound. A limited follow up transvaginal scan, such as for follicular monitoring or a cyst check, is simply reported as 76857, and no modifier necessary.
S4042 Management of ovulation induction (interpretation of diagnostic tests and studies, non face – to – face medical management of the patient), per cycle.
Monitoring by nurses CPT
99211 is a code for the evaluation and management of an established patient.
Key points for using this code include:
- The presence of a physician is not required.
- Typically five minutes are spent with the patient.
- The presenting problem is typically minimal.
- Some sort of E+M is required- limited assessment or decision-making must occur. For example, this would not be appropriate if the patient was coming to the office to pick up a sample jar to collect a semen sample at home.
- The service must be separate from any other procedure that day. For example, collecting a urine sample from a patient that is being evaluated by the physician for a possible infection would be included the physician’s E+M coding.
- Although the physician is not required to perform the service, the physician should be in the facility at the time of the service.
- Documentation does not require any key components (like is found in codes 99212 through 99215). Instead, the visit should be documented, including why the visit was necessary and what was done. Some sort of limited assessment or decision-making should occur.
This code requires a face-to-face encounter, a phone conversation is not billable. However, if the nurse meets with a patient to review how to give an injection, or evaluates a patient who has a sore site after an injection, those encounters may meet the criteria of 99211.
Infertility consult by nurse
Diagnosis codes (ICD-10-CM) and procedure codes (CPT) are the same for everyone! That includes nurse practitioners, PA’s, sonographers, nurse midwives, embryologists, etc. But, in order to bill, each provider will have a provider ID number. This identifies to the payer the name of whom is rendering the service. Nurse practitioners are usually reimbursed at a discount relative to what an M.D. would be paid.
Patient education
Education sessions are used by many IVF practitioners before patients begin their first cycle. When a physician provides an educational seminar in a group setting, one can report 99078. Educational seminars given by nursing personnel may be reported as 99071. Third party payers don’t reimburse well for either of these codes. Additionally, 99211 can be used for education services by non-physician staff. The only requirement to bill for this is that teaching is at least five minutes and the physician is in the office during the E/M service. Another option is to use an unlisted special services code: 99199. You can bill for this service, but you are likely to be reimbursed only by your self-paying patients. Lastly, some practices choose to bill the patient a fee for a group educational session, and to not bill insurance.
Telephone consult
There are specific guidelines for a telephone consultation; these guidelines are in the appendix of the CPT manual (published yearly by the AMA).A nurse phone call to provide the patient with results is not reimbursable as it is considered part of performing a test.
IVF counseling
All surgeries and procedures are valued by CMS with attention to the time and effort spent in routine pre-op and post-op care that pertains to that specific surgical procedure. When RVUs are assigned, the time devoted to reviewing and signing the consent form is included in that valuation. The time spent in going through the informed consent process for the oocyte retrieval (the only part of IVF that has RVU assigned to it) is bundled into the reimbursement for that procedure. However, the time spent going through the informed consent process for all other aspects of IVF is not included. A practitioner may bill for face-to-face time if time is spent with the patient making the decision for treatment with IVF, teaching about the IVF process, reviewing certain interventions (ICSI, PGT, etc.), and discussing the risks of IVF such as aneuploidy, multiple gestations, etc.
When programs bill IVF under a global fee, they traditionally apply a single fee to cover all services in a routine IVF cycle. Centers that bill with a global fee are typically not using CPT codes, so the rules of CPT may not apply.
Monitoring FET ICD
The correct diagnosis will depend on the patient’s history. Typically, it is an infertility diagnosis (N97.X) ---due to anovulation, male factor, uterine factor, cervical factor, etc. However, there may be a genetic diagnosis if there was a preconception genetic carrier status.
CPT US Embryo Transfer in Surgery Center
The Embryo transfer, intrauterine [CPT code 58974] only includes the actual performance of the transfer by the physician. This code does not include either the Preparation of embryo for transfer (any method) [CPT code 89255] or the ultrasound performed for guidance of the embryo transfer..
There is not a specific code for ultrasound guidance of the embryo transfer. However there are ultrasound codes that can be used for this procedure: 76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up). This would be appropriate since an ultrasound of the uterus to guide the embryo transfer is an ultrasound of a single organ and therefore fits the definition.
76998 Ultrasonic guidance, intraoperative. This code is utilized in the operating room by the surgeon or ultrasonologist as per the ACRs Ultrasound Coding User’s Guide 2010. This may be the reason why the auditing company is recommending this more specific code. Either of these 2 codes could be used to describe the ultrasound guidance for the embryo transfer.
Infertility consult by nurse
Diagnosis codes (ICD-10-CM) and procedure codes (CPT) are the same for everyone! That includes nurse practitioners, PA’s, sonographers, nurse midwives, embryologists, etc. But, in order to bill, each provider will have a provider ID number. This identifies to the payer the name of whom is rendering the service. Nurse practitioners are usually reimbursed at a discount relative to what an M.D. would be paid.
Patient education
Education sessions are used by many IVF practitioners before patients begin their first cycle. When a physician provides an educational seminar in a group setting, one can report 99078. Educational seminars given by nursing personnel may be reported as 99071. Third party payers don’t reimburse well for either of these codes. Additionally, 99211 can be used for education services by non-physician staff. The only requirement to bill for this is that teaching is at least five minutes and the physician is in the office during the E/M service. Another option is to use an unlisted special services code: 99199. You can bill for this service, but you are likely to be reimbursed only by your self-paying patients. Lastly, some practices choose to bill the patient a fee for a group educational session, and to not bill insurance.
There are specific guidelines for a telephone consultation; these guidelines are in the appendix of the CPT manual (published yearly by the AMA).A nurse phone call to provide the patient with results is not reimbursable as it is considered part of performing a test.
IVF counseling
All surgeries and procedures are valued by CMS with attention to the time and effort spent in routine pre-op and post-op care that pertains to that specific surgical procedure. When RVUs are assigned, the time devoted to reviewing and signing the consent form is included in that valuation. The time spent in going through the informed consent process for the oocyte retrieval (the only part of IVF that has RVU assigned to it) is bundled into the reimbursement for that procedure. However, the time spent going through the informed consent process for all other aspects of IVF is not included. A practitioner may bill for face-to-face time if time is spent with the patient making the decision for treatment with IVF, teaching about the IVF process, reviewing certain interventions (ICSI, PGT, etc.), and discussing the risks of IVF such as aneuploidy, multiple gestations, etc.
When programs bill IVF under a global fee, they traditionally apply a single fee to cover all services in a routine IVF cycle. Centers that bill with a global fee are typically not using CPT codes, so the rules of CPT may not apply.
IVF Facility Fees should be used for the cost of use of supplies and for in-office surgical procedures to maintain the surgical facility. This would include for facility costs of the outpatient procedures including IVF retrieval and embryo transfer.
- Reusable supplies/equipment: the cost of use of these supplies are built into the charge for the procedure.
- Disposable supplies: can be charged for if the individual unit cost is >$25 and use of the supply is documented in the chart.
- Facility billing is limited to hospital-based clinics. Facility billing is the hospital’s technical charge for services provided in an outpatient department of a hospital. Unlike physician-based billing, facility costs are not built into the hospital reimbursement structure (ex: facilities/maintenance, lighting/electricity). The facility fee is essentially reimbursement for the use of hospital space and resources.
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