The World Health Organization (WHO) says infertility is one of the common issues in both men and women. Infertility has billable codes under the International Classification of Diseases. This helps doctors charge patients and insurance companies. The Centers for Disease Control and Prevention (CDC) says almost 19% of women struggle to conceive., while male infertility is also increasing.
Infertility-related claims are common. But how you code them is very important, especially when you are assigning diagnosis and procedural codes. Using specific symptoms instead of N97.9 (Female infertility, unspecified) can help a lot. Many infertility claims get denied because most insurers do not cover these treatments unless state law requires it. Right now, only 18 states mandate some coverage. Many payers reject claims when they see “infertility” in them.
But you can still improve your chances. How? By making your billing process more efficient. The good news is, you can have a strong fertility clinic billing system and healthy cash flow by just following the tips below!
3 Proven tips for handling common fertility clinic billing scenarios:
1) Documenting the symptoms of your female patients perfectly:
Infertility often comes from an underlying issue. The first visit is usually to find the cause, not to treat infertility directly. For example, a woman comes to the clinic with chronic pelvic pain (R10.2, Pelvic and perineal pain). She also mentions trouble getting pregnant. You listen and ask more questions. After more checks, you find she has endometriosis (N80.0-, Endometriosis of the uterus). This condition can cause pain and affect fertility.
The solution is pretty simple. You should always assign the main diagnosis code for the first visit and then, you must assign the follow-up code. This shows how important it is to document symptoms clearly. Never code for conditions that are only suspected to ensure a perfect fertility clinic billing solution.
2) Assigning the accurate consultation code:
Always use the correct consultation codes (99242-99245) when a primary care doctor refers a patient for infertility concerns. For example, a patient comes with irregular periods (N92.6) and cystic acne. Her primary doctor referred her to check for PCOS. You carefully review her symptoms and run tests. After checking, you confirm PCOS (E28.2). You share the results with the referring doctor for further care.
The solution is clear. Use the right consultation code from 99242-99245. List all diagnoses: N92.6 (irregular periods), L70.0 (cystic acne), and E28.2 (PCOS). Do not use only E28.2, as it can cause claim denials. Now you understand how wrong coding can affect fertility billing. Insurance companies like detailed records. Adding all the correct code helps you get approvals faster. It also ensures proper payments and fewer delays.
3) Assign proper diagnosis codes for male fertility issues:
Many conditions can cause infertility in men. Common ones are low sperm count, poor motility, hormonal issues, and blockages.
For example, a patient comes to you worried about low sperm count. His urologist referred him to your clinic. You listen to his concerns and order tests. After checking the results, you confirm oligospermia (N46.01, Oligospermia, unspecified). This condition affects fertility and may need treatment. A proper diagnosis helps to plan the right care.
The solution is simple. Use N46.01 as the primary diagnosis. If tests also show varicocele (I86.1, Varicocele), record both conditions carefully.
You must always use accurate diagnosis codes. Insurers need clear details to process payments. Avoid generic codes to reduce the risk of denials.
The situations you read about are common in fertility clinics. But sometimes, you may face more complex cases. That’s why you need a strong understanding of coding and billing to get paid on time. Sadly, many fertility clinics do not have enough staff to manage these tasks well. Are you facing the same problem? Don’t worry! You can easily outsource your fertility clinic billing.
A professional billing company handles the full revenue cycle for you. They make sure your claims are correct, and payments come on time. This way, you can focus fully on patient care without stress.
So, what are you waiting for? Get a billing partner today and enjoy steady cash flow while giving your patients the best care!
