Infertility is more common than many people realize in the U.S., affecting approximately 8.5% of married women between the ages of 15 and 49. Therefore, the demand for fertility treatments continues to grow.
Assisted Reproductive Technology (ART), including In Vitro Fertilization (IVF), offers hope to many such women and families. It contributes to 2% of births (8 million babies, to be specific) in the country. However, this treatment is expensive, requiring accurate coding and billing for every step.
Follicle puncture is an essential ART procedure, billed under a straightforward CPT code 58970. Read on to learn this code’s correct usage and best billing practices!
CPT Code 58970 – Description
CPT code 58970 refers to a surgical procedure used in In Vitro Fertilization (IVF). More specifically, this code reports follicle puncture for oocyte (egg) retrieval. So, what exactly is a follicle, and what happens during this procedure? A follicle is a fluid-filled sac in the ovary containing an immature egg. There are thousands of follicles in the ovaries.
During this procedure, a doctor, most likely a gynecologist or fertility specialist, gently inserts a fine needle through the vaginal wall to access the ovarian follicles and aspirate (suck out) their contents (fluid and the egg). This entire process is performed under ultrasound guidance to ensure accuracy and safety.
Follicle puncture is a crucial step in IVF, allowing healthcare providers to retrieve eggs for fertilization in a laboratory. In short, CPT code 58970 specifies the process of collecting eggs from a woman’s ovaries using a thin needle.
Scenarios Where CPT Code 58970 is Applicable
We have provided a simple explanation of CPT code 58970. Now, here are three specific scenarios of using this code so you can understand its application:
Follicle Puncture for a Patient with Diminished Ovarian Reserve
Many women seeking fertility treatment are diagnosed with diminished ovarian reserve (DOR). Let’s consider this scenario! Suppose a 34-year-old woman, after trying to conceive for 2.5 years, visits a fertility specialist on her friend’s recommendation.
After a thorough evaluation, the doctor learns that she has irregular periods and decides to assess her ovarian reserve using blood tests and ultrasound. The healthcare provider diagnoses her with diminished ovarian reserve (DOR) and recommends an IVF treatment.
Once the patient’s follicles reach an appropriate size (greater than 14 mm) under hormone stimulation, the doctor administers a trigger shot to finalize egg maturation. She then performs a follicle puncture under ultrasound guidance to retrieve the patient’s eggs for fertilization. The billing team then uses CPT code 58970 to report this surgical procedure.
Egg Retrieval for a Cancer Patient’s Fertility Preservation
Some cancers and cancer treatments, such as chemotherapy, can negatively impact fertility in women. Let’s assume a 29-year-old woman is diagnosed with breast cancer and is scheduled to undergo chemotherapy. Before her diagnosis, she was actively trying to start a family.
Concerned about her fertility, she consults her gynecologist, who informs her that chemotherapy may compromise her ovarian reserve. Therefore, she decides to freeze her eggs before starting chemotherapy.
The doctor places her on hormonal injections. She performs oocyte retrieval using a fine needle under ultrasound guidance once her follicles grow beyond 14 mm. Her billing team then uses CPT code 58970 to bill for this egg retrieval procedure.
Egg Retrieval for Donation
Did you know that poor egg quality and diminished ovarian reserve can result from various factors, including aging? Here is an example! Suppose a 39-year-old woman is struggling to conceive due to poor egg quality. Her 26-year-old cousin steps in and volunteers to be an egg donor.
Before the procedure, the doctor performs several tests, including psychological screening and ovarian reserve assessment, to determine if she is the right candidate. After confirming her eligibility, the gynecologist prescribes hormonal medications to induce ovulation.
Once her eggs are mature, the healthcare provider performs follicular puncture under ultrasound guidance to retrieve the eggs and reports this procedure using CPT code 58970.
Applicable Modifiers for CPT Code 58970
CPT code 58970 typically does not require modifiers. However, you can apply the following modifiers to this code in certain situations:
Modifier 59
Modifier 59 helps insurance companies distinguish unrelated services. You can use this two-digit code with CPT code 58970 if it is distinct and separately identifiable from another service (e.g., an endometrial biopsy) performed on the same patient on the same day.
However, try to use one of the X{EPSU} modifiers instead of modifier 59 if they are applicable.
Modifier 53
Although follicle puncture is a minimally invasive procedure with a low risk of complications, patients can still experience bleeding and infections. So, if you discontinued the procedure after administering anesthesia due to extenuating circumstances, you can use modifier 53 with CPT code 58970.
CPT Code 58970 – Billing & Reimbursement Guidelines
Looking for the best billing and documentation tips for CPT code 58970? You can follow these instructions:
Justify Medical Necessity with Complete Documentation
Follicle puncture is an important part of IVF treatment. However, insurance companies only cover it if it is medically necessary based on the patient’s condition. Therefore, document the following details to justify this procedure:
- Reason for the procedure (e.g., poor egg quality, DOR, fertility preservation due to aging or disease)
- Appropriate diagnostic (ICD-10) code (E28.8 for ovarian dysfunction, N97.0 to N97.9 for female infertility, E28.2 for PCOS or Z31.84 for fertility preservation)
- Ovarian stimulation details (e.g., the medication used, patient’s reaction to the medicines, follicle sizes before egg retrieval)
- Operative details (e.g., anesthesia used, ultrasound guidance, number of follicles aspirated)
Apply Appropriate Modifiers (If Applicable)
As we mentioned earlier, CPT code 58970 generally does not require modifiers. However, you can apply them to communicate additional information, such as a distinct service or discontinued procedure.
Verify Insurance Coverage
Keep in mind that Medicare and Medicaid do not cover IVF or other fertility treatments. However, some private insurers do. But, IVF coverage laws vary by state. Therefore, review and verify each payer’s ART and IVF insurance coverage policies and obtain prior authorization if it is required before billing for CPT code 58970.
Conclusion
Did we clear up some of your confusion? CPT code 58970 is one of the most essential codes in gynecology billing services. It refers to an important IVF surgical procedure, follicle puncture, where healthcare providers use a needle to aspirate ovarian eggs.
We have covered this code in detail so you can use the right approach to minimize your losses while maximizing reimbursements. Just remember to justify the medical necessity of this procedure, document everything, and verify the insurance coverage.
