FAQs in Male Infertility Coding and Billing

Q1. How can one determine which carrier will or will not pay for infertility services and studies?”

Answer: That has been a problem for urology offices for the last few years. Fortunately, more and more carriers are paying for infertility services and studies so this doesn't become a big problem. Where there is a question of payment such as a patient that's going to have a sperm aspiration or PESA or a MESA or a TESA, my suggestion would be that you have the patient pay you for the procedure and then tell the patient that you are going to bill their carrier. And if the carrier does reimburse for the procedure, you will immediately return the payment that the patient made to the patient and you will accept the payment from the insurance company.

Be very careful that when you do one of the sperm aspiration procedures that are expensive and most of the time are not covered by the carrier, if the carrier sends you back payment and changes your code, let's say that you're going to use the code 55899, the unlisted code for the male genit – male genital system. if they change the code and make it a biopsy of the testicle whether it's incisional or needle and that pays relatively small amount as compared to what you will be charging the patient for your aspiration, then you – then I would advise you, send back immediately the money, the check from the company with an appeal that you want to be paid for not a biopsy – because that's not what you did – you did a micro – you did a microscopic or microscopic technique testicular aspiration.

So that's how – I think you should get paid up front and tell the patient that you will submit their insurance and if paid appropriately, you will send them back – you will send them back their payments and accept the insurance payment. Okay.

Q2. How would I code a microscopic single tubule biopsy of two different seminiferous tubule groupings of the left testes?

Answer: Firstly, speak to the family (the husband and wife). And after that you're going to be doing a microsurgical technique of these procedures. You know, you're going to a microsurgical, say, an epididymal sperm aspiration under the microscope, you know, the operating microscope.

And most carriers will not pay this although some carriers do. But I would talk to the patient, “Whatever your fee is, I would get paid,” ask the patient to pay you with the understanding that you are going to submit this claim. And if the claim is paid appropriately, then you are going to immediately send them back what they paid you and accept the payment from the insurance carrier.
The only thing you – and that's what I would do. The only thing you have to worry about is that if the carrier changes your code and makes it a testicular biopsy – and that's not what it is – and they pay you on the basis of a testicular biopsy, you immediately send that money back to the carrier and tell them that that's not what you did and file an appeal because. And if you accept that money for a lesser procedure, there's nothing that you can do. You have to give the money back that the patient gave you. But don't accept it if it's not what you really did. And they will do that – the carrier will pay you a less – they'll change the code and pay you less.

Q3. When my urologist performs a varicocelectomy to improve male infertility, shouldn't the diagnosis be 606.1 oligospermia as the medical reason for the surgery rather than varicocele?

Answer: You see, the problem is that you are doing a varicocelectomy to help improve male infertility with the – the male infertility is oligospermia, 606.1. However, if you bill the 606.1, most carriers will not recognize that as a diagnosis for doing a varicocelectomy. So the best way to handle that is to bill the varicocelectomy with the diagnosis, varicocele. That's what you have. So you're thinking of a – it's 456.4. Now, your secondary diagnosis should be the 606.1. Remember that a carrier will only see the first diagnosis and pay on that. And you are absolutely completely perfect and you're calling it as it is, there is a varicocele that's why you're doing the varicocele. The 606.1 as the secondary diagnosis becomes an informational diagnosis and not really a diagnosis of medical necessity. But it is important to put that down.