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    Registered User Lycos's Avatar
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    Exclamation "Getting Insurance to Cover PCOS!!! READ THIS!!!"

    Check out this article I found while fuming over PCOS being considered "infertility" only and thus not covered by my insurance. Hope others find it as useful as I do (hopefully I can make it work out!). This article was written for medical coders, but maybe showing it to a doctor will help them and whoever does their coding to get PCOS treatments covered. Remember, the doctors want to get paid as badly as we want to be treated!


    Are You Using Only 256.4 to Report PCOS? Think Again

    Signs and symptoms coding is the key until you have a definitive diagnosis

    Too often, carriers refuse a polycystic ovarian syndrome (PCOS) diagnosis because it indicates infertility, and they don’t pay for infertility treatments. But you can get paid for treating suspected PCOS because the patient usually has other symptoms.
 
PCOS isn’t simply a fertility problem. Unfortunately, many insurance carriers either don’t understand that fact or choose to ignore it.
 
The problem often arises when an insurance carrier receives a claim listing only a PCOS diagnosis. If the patient has received diagnostic testing or treatment for suspected PCOS, the carrier assumes that the patient is receiving fertility treatment and automatically issues a denial. So by coding the patient’s condition as 256.4 (Polycystic ovaries) before you have a definitive diagnosis, you’ve fallen into a coding trap and effectively denied your practice reimbursement for services rendered to that particular patient.

    Code the Chief Complaint First

    If you don’t report the initial diagnosis as PCOS, how should you code it? The key is to code the chief complaint. A patient generally doesn’t walk into your office and say, “I have PCOS.” A patient usually walks in and says, “I haven’t had a period in four months. What’s wrong with me?” In that case, look to the codes for irregular menses (626.4) or hypomenorrhea (626.1) or other disorders of menstruation (626.8).
 
PCOS isn’t always easily diagnosed, and coding the complaints provides certainty. If there’s any question whether the patient has PCOS, you should code the secondary characteristics. 
 
“Never use probable, suspected or rule out for physician diagnosis coding,” says Lynn M. Anderanin, CPC, senior coding consultant for Healthcare Information Services LLC in Des Plaines, Ill. “You must use the signs, symptoms, or a confirmed condition or disease.”

    Don’t Overlook Nonmenstrual Complaints

    You should be aware of other signs and symptoms associated with possible PCOS. Many (if not most) women with suspected PCOS come to the ob-gyn not because they want to conceive a child, but because they want to treat their physical symptoms, which can include inability to menstruate regularly or at all, excessive hair growth, sudden hair loss, unexplained weight gain, and chronic acne. Many of these women simply want a normal menstrual cycle, not a pregnancy. In fact, women can develop PCOS manifestations throughout their lives, not merely during their childbearing years.
 
PCOS symptoms can include hirsutism (704.1), alopecia (704.0x), abnormal glucose tolerance test (790.2), cystic acne (706.1), obesity (278.00) and many of the disorders associated with an abnormal lipid panel (272.x).
 
But remember, Anderanin says, “I always tell my students that the diagnoses describe why the patient is being seen today. The patient may have other conditions, but if they are not related to today’s visit, they should not be used for the diagnosis.”
 
The bottom line is you have to link the proper diagnosis codes to a procedure. If the ob-gyn provides an E/M service, then the insurance carrier shouldn’t deny payment if you report the signs and symptoms. But what if the physician performs a pelvic ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) to see whether a patient’s ovaries really are polycystic? You can’t submit an ICD-9 code for obesity and expect an ultrasound to be covered unless your note says, “Because of obesity, I was unable to perform a proper pelvic exam.” But if the patient also has irregular menses (626.4), you can report that, and the carrier will likely pay for the ultrasound.
 
“Coders must be careful to code what is documented in the medical record, not to fix the patient’s coverage,” says Peggy Stilley, CPC, office manager for Women’s Healthcare Specialists, an Oklahoma University-based private ob-gyn practice in Tulsa.

  2. The Following 9 Users Say Thank You to Lycos For This Useful Post:

    Chachafance (01-22-2012),CIP121910 (01-02-2012),Faery Chaos (11-06-2011),FaithHopeandLove (02-06-2014),fighting_pcos (06-18-2013),lisichance (11-12-2011),sunshinegal (06-12-2013),tot-tot (01-03-2013),_dawniiboo_ (06-21-2014)

  3. #2
    Registered User kychica718's Avatar
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    This is very timely for me. I just received a large bill from some recent blood work, gyn visit, and ovarian ultrasound. This was the first time i gotan actual PCOS diagnosis...after years of suffering. The bill included a note about the insurance company needing more info, so I called them today. Upon speaking to the representative, she informed me that I didn't have coverage since seeing a doctor for PCOS was the same as seeing a doctor for infertility. I was shocked. I did not go to the doctor about infertility. I went due to irregular periods (bleeding for 40 days at a time and then not having a period for 56 days, etc.) and other symptoms such as fatigue, acne, hirsutism, etc. I wanted to make sure not having periods regularly wasn't doing permanent damage to my body. After all, women are DESiGNED to ovulate! It did come up that i may have trouble conceiving down the road and that we could address it when the time came, but that was not what prompted my visit. Nor was i prescribed any fertility type meds. I just find it so insulting that if a woman seeks medical help for PCOS, the insurance company automatically assumes it's because we are having a hard time getting pregnant! Can't we be concerned about our overall health? It isn't just a fertility issue--it's an EVERYTHING issue. In my case, the doctor's office is going to update the codes they used and send a copy of the office notes if necessary (the insurance requested those--are they allowed to do that?). I'll post an update when I know how this ends up playing out.

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    Follistim Lover PetiteFlower's Avatar
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    In this case you should have contacted your doctor's office first, since they are the ones who can provide the additional information needed and resubmit the claim.
    Emily (36) & DH Kevin (37), married 10/24/10
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    Registered User Audi10's Avatar
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    I dont have anything thing to add really as my ins covers all my u/s so far, except from the RE since they code it as fertility, but i get most of my monitoring done at my local hospitals so my re sends it as checking on my pcos. I did want to comment on kychica asking if the drs office is allowed to share info with the ins company. WHen you go to a drs office and fill out your paper work one if the papers is HIPPA and its required they notify you of your legal rights. It explains that they will not share your personal info with just anyone but it allows them to share it a person you give right to do so and your insurance company, so yes they are allowed to do that. Hope that helps =) I wish we all could have good ins, mine I have been lucky has paid sooooo much, but let me tell ya I pay for it with my part of my premium, my employer pays half and I pay half, it totals over $6500 a year combined, just for me. My dhs ins is less then half of my monthly cost for himself, but with less coverage in the areas I need I gotta keep what i have until I get knocked up lol!
    ME (27) & DH (33) +
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    Registered User kychica718's Avatar
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    I am keeping a positive attitude until I get a definite "no." I think with the doctor resubmitting the claim, the insurance will end up paying. The doctor's office seemed to act like they have had this issue before with *certain* insurance providers (ahem, Humana) and that they knew how to address it. What upset me was that the insurance automatically assumed, "oh, PCOS? You must be having conception issues. Claim denied!"

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    Follistim Lover PetiteFlower's Avatar
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    Honestly, even without specific permission, your doctor can always share your information for the purposes of either treatment or payment. So they can share info with your insurance company to get your bills paid even if they don't have a signed authorization for it. The HIPAA disclosures you sign at the doctors office generally just say that you have received a copy of their HIPAA policy. They will sometimes have you sign an authorization for your insurance company anyway, but it isn't officially necessary.
    Emily (36) & DH Kevin (37), married 10/24/10
    9/22/12 ECTOPIC pregnancy
    10/17 Clomid cycle, no response
    12/1 Higher dose clomid cycle - O, BFN
    1/3 Follistim cycle - OHSS, Chemical pregnancy
    2/11 Follistim cycle 2, lower dose - BFP 3/4! EDD 11/13/13
    3/6 beta 197, p4 33.6! 3/11 beta 1593!
    It's a BOY! Samuel Jacob born 11/2/13 at 38w3d
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    Registered User Hwhitt00's Avatar
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    I have no idea what to do, I was recently diagnosed with PCOS and it was shortly after getting new health insurance (talk about bad timing!!!) So now I am getting all of these bills and letters from United Health Care stating that I had a pre-existing condition that I failed to mention to them, and they are refusing to pay anything. (I did NOT know I had PCOS and I am so disappointed with this all!)

    Have any of you ladies dealt with United, and if so how did you handle this?

    Thank you!

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    Registered User Audi10's Avatar
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    I would call yourDrs office and speak with the ins clerk... they should be able to straighten it out for you!
    ME (27) & DH (33) +
    DS (1 - born 6/12 on due date) & DD (born 1/14 @ 35wks 3days) =
    FAMILY COMPLETE!

  10. #9
    Happy to finally be a Mom redsoxfan's Avatar
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    You should be getting (or have already gotten) a form from UHC asking if you have received treatment from any providers in the look back period (you need to read your insurance documents specific to your plan on how far back they go) A condition is only pre-existing if you have had a lapse in insurance coverage greater than 63 days.. if so and you were treated for PCOS during that time, then it IS a pre-exisiting condition and they can deny coverage for that specific condition. If you had no lapse in coverage, all you need to do is submit a certificate of coverage from your previous insurance carrier and that will solve the problem. If you weren't treated for PCOS and didn't have insurance coverage then you would need to communicate that with UHC, but they will ask you for a list of doctor's you've seen in the past year. Pre-existing conditions are not a policy specific to United Healthcare, it's standard insurance practice and the specifics of the policy are actually dependent upon your employer benefits, not the insurance carrier unless it's an individual policy or a small group policy.

    The insurance contact at the doctor's office can only assist in sending your medical records. United Healthcare needs information from you to overturn any denials.

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    Registered User hoping4miracle2012's Avatar
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    I had a problem once with my old insurance company, They wouldn't pay anything because they said its a pre existing condition, but all the insurance company wanted was a letter from my prior insurance company that said I had coverage from a certain date. I also told my doctor I didn't have infertility coverage with that insurance company and she would code everything as "ovarian dysfunction" She even gave me a rx for clomid but sadly I didnt start clomid because my fiance job changed insurance company all of a sudden and no longer would cover common law marriage.

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    Registered User 2mommiesnj's Avatar
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    Great information!


    Thanks

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    Registered User medievalgirl's Avatar
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    This is a great thread, thank you. I think that PCOS women are getting screwed (excuse my language) by our health care system. Along with learning the ways to code, we also need to advocate for ourselves. Why is it ok that so few insurances cover infertility?

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    Registered User Monsterbean1538's Avatar
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    Thank you so much for this helpful information!

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    Registered User doublegwammy's Avatar
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    I also have United Health Care and under my plan, I am covered (in network) up to $5,000. However, I'm sure we all know how fast that can go. Very grateful for the coverage right now though. My dr's office put the incorrect cpt code in for my hysterosalpinogram and I was going to be charged. However, I made a call to the insurance company (to see why they weren't covering it) and they called the dr's office while I was on the phone and got the correct code. I think wherever insurance is concerned, it is VITAL that we all do ourselves a favor and pick apart the bills, pre-certs, etc. All it takes is one wrong keystroke and you could be out thousands that you are entitled to. Also, explain to your dr what your insurance will and won't cover. Ask him to please code it as something that is covered if possible, like the most outstanding symptom. Hopefully, especially those who are just trying to get their PCOS symptoms under control and not trying to conceive, will be able to get some help.

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    Registered User berichard's Avatar
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    Angry

    This is really frustrating to read, simply because I just don't understand how PCOS became synonymous with infertility issues. I am 24, single, and living on my own and have no interest in becoming pregnant any time soon. I was diagnosed when I was in high school because of the serious depression I was suffering from. To be honest, even on these message boards I become extremely frustrated with all the talk of pregnancy. I would love to be able to go to a doctor that understands that having PCOS IS a big deal to me NOW, not just in the future if I ever want to conceive. Isn't there anyone else who is in this boat with me!?!?!

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