Ob-Gyn Coding Alert

Question: A new patient scheduled a well-woman visit, and as the reason for the visit she indicated: Yearly checkup, inability to conceive for four years. The physician did a routine exam, discussed infertility and ordered lab tests, and gave her husband a referral for semen analysis. He also discussed scheduling hysterosalpingography (HSG). The physician feels it should be coded as a well-woman exam rather than infertility, but my inclination is to code infertility as the primary reason for the visit. Who is correct?

California Subscriber 
 
Answer: Because the primary intent of the visit was a well-woman exam, that should be the primary code. If the physician encounters a new problem or addresses existing ones that require significant work, you could code for both the preventive care visit and a separate E/M service per the CPT guidelines.
 
You should code for the preventive service for a new patient first, using 9938x (initial comprehensive preventive medicine evaluation and management of an individual), with V72.3 (gynecological examination) as the diagnosis. Then, code for a problem-oriented E/M visit for a new patient, 9920x (office or other outpatient visit for the evaluation and management of a new patient), with 628.9 (infertility, female; of unspecified origin).
 
You will be using a new patient code for each service because the patient is new to the practice at the current encounter. Add modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code. Some payers accept only a single E/M code per service date, and you may have to decide which service constituted the most significant physician work and bill only for one.
 
Because reimbursement for infertility treatment varies by carrier, you might find that the problem service is not covered under the patients health plan. She will be responsible for a portion of the bill if using two E/M codes or all of the bill if using the problem E/M code. Before discussing infertility or ordering any tests, you should tell the patient that her carrier may not reimburse for that portion of the encounter.