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Linking documentation for fertility services to medical necessity

Physician Practice Insider, July 27, 2016

Correct coding is important to physician practices. The ICD-10-CM diagnoses and the CPT procedures need to be linked appropriately, and clearly show the medical necessity of the testing or procedures being performed. The most common denial from insurance carriers is “procedure is deemed not medically necessary.”

Coding for infertility is complicated, and errors are not uncommon. Coders need to clearly understand the most common codes utilized in infertility procedures and diagnoses. Best practices contact the patient and obtain prior authorization and check insurance benefits before scheduling and/or performing any major infertility procedures.

Pre-authorization and medical review have become necessary components for payment by third-party payers such as insurance companies. These carriers carefully review the patients’ policy and will advise of any conditions or policy criteria that specifically addresses infertility treatments. It has become commonplace language in most insurance policies that all medical treatment be medically necessary, not just treatment for infertility.

Unfortunately, some insurance carriers provide minimal or even no payment for infertility testing or procedures. When pre-authorizing for infertility testing or infertility procedures, be sure to carefully review and discuss the patients’ policy with the patient, and then have the appropriate advance beneficiary notice (ABN) signed, and/or financial commitment for payment if the insurance company does deny payment, or if the patient does not have any third-party coverage at all.

This article originally appeared on JustCoding. Members can read the full article here. If you are not a member, click here to register for free to read the full article.

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