Question: We are a fertility practice, and we’re seeing a patient who may have had Clomid treatments or other medication cycles with her ob-gyn prior to coming to us. Our physicians want to evaluate her status by performing a saline sonogram and some other gauging lab work. What diagnosis should I use as the primary if the patient is not in a medical cycle or being monitored for medical cycle? Should I report 628.x? The patient already had treatment from her prior ob-gyn for a fertility issue. Should I instead use V26.21 as the primary (or secondary diagnosis to 628.x)?
Answer: If your physician is evaluating the patient to find the cause of her infertility, you are in the testing or counseling phase, and you should use V26.21 (Fertility testing) or V26.49 (Other procreative management counseling and advice).
You should report 628.x (Infertility, female) only when the ob-gyn has confirmed the patient is infertile and knows the cause. If your ob-gyn knows the patient is infertile and does not know the cause, you could use 628.9 (… of unspecified origin).
Before settling on the above options, consider doing some more hunting. Check for the diagnosis used by the previous ob-gyn who did the treatment. Was a definitive diagnosis given at the time of treatment? If the other physician diagnosed polycystic ovarian syndrome (PCOS), for instance, you would use that code (256.4, Polycystic ovaries) until your ob-gyn establishes some other cause.
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