READER QUESTIONS:
Stick to Your Primary Dx
Published on Tue Sep 26, 2006
Question: The patient had a diagnostic laparoscopy and hysteroscopy. The ob-gyn's pre-op dictation states, -Planning this surgery for evaluation of failure to conceive. She also has significant right-sided pain at the time of each ovulation.- I submitted the charges with 628.9 as the primary diagnosis. The payer denied the procedures because it does not cover the infertility diagnosis under the patient's contract. The patient now wants me to resubmit the procedures with her right-sided pain as the primary diagnosis. Should I resubmit it?
Kansas Subscriber
Answer: You should not resubmit your claim. The patient came in to see the ob-gyn because she could not get pregnant (628.9, Infertility, female; of unspecified origin), not because of the right-sided pain. The ob-gyn performed the procedures to diagnose infertility.
Check her payer policy to be sure she has no coverage for infertility, because some companies will pay for testing and diagnosis, but not treatment. Also, if you are in an infertility -mandated- state, there may be legislation that overrides insurance company policy.
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