Fertility is one of the most crucial parts of human health. Yet, according to the National Institute of Child Health and Human Development (NICHD), about 8% of men and 11% of women are suffering from some form of infertility in the United States. In this situation, fertility treatments like In Vitro Fertilization are nothing short of a miracle. 

At the heart of these procedures lies a series of carefully executed steps. One of these steps is the oocyte or egg extraction, which is billed under the CPT code 58970. But what exactly does this code define, and how can you use it practically in your billing?

That’s what we are going to find out in this blog. We will break down everything you need to know about this code. We will discuss the code’s description, real-world scenarios, applicable modifiers, and tips for successful reimbursement. So, let’s start. 

CPT Code 58970 Description

CPT code 58970 is officially defined as “follicle puncture for oocyte retrieval, any method.” In simple terms, this code is used to bill for the procedure where a healthcare provider retrieves eggs from a woman’s ovarian follicles, which are then used in treatments like in vitro fertilization (IVF). IVF is a process in which eggs are collected and then fertilized in a laboratory. 

The procedure itself is very straightforward. During the procedure, the healthcare provider uses a needle to make tiny punctures in the patient’s ovarian follicles, which are little fluid-filled sacs in the ovaries that house the eggs. The fluid is aspirated slowly, and the eggs are collected. 

An important thing to note here is that CPT code 58970 is used only for follicle puncture for oocyte retrieval and has no relation to the retrieval method. The retrieval can be done via a transvaginal approach or another method and does not affect reimbursement for 58970. 

Appropriate Use Cases for CPT Code 58970

To better understand the use of CPT code 58970, let’s look at a couple of real-world scenarios where this code can be used.

Blocked Fallopian Tubes

Suppose a 32-year-old woman has been struggling to conceive for two years due to blocked fallopian tubes. She visits her gynecologist, who diagnoses that due to previous pelvic infections, the tubes are now blocked. In this situation, natural conception is nearly impossible, so her doctor recommends IVF.

Some medications are given to her to stimulate her ovaries to produce multiple eggs. These oocytes are then surgically retrieved via a minor procedure. The gynecologist then uses CPT code 58970 to bill for the oocyte retrieval process. 

Male Factor Infertility

A couple faces infertility because the male partner has a sperm count that is too low for natural conception. 

They visited a gynecologist, and as a possible treatment, the specialist suggested IVF with intracytoplasmic sperm injection (ICSI). This is done to improve the chances of fertilization. 

To start the treatment, the wife undergoes a minor surgery, which is a transvaginal ultrasound-guided procedure to retrieve the eggs from the fallopian tubes, billed using CPT code 58970. Each egg is then injected with sperm in the lab, and the resulting embryos are then transferred to the uterus. 

Modifiers to Append CPT Code 58970

To provide more details about the procedure, one or more modifiers are often appended to CPT codes. The following are some modifiers that can be used with CPT code 58970:

Modifier	Description	Applicability to 58970
22	Increased procedural service for greater complexity.	Applicable if the procedure is more complex, e.g., due to patient anatomy or complications.
51	Multiple procedures or secondary procedures in the same session.	Applicable if 58970 is one of the multiple procedures reported on the same date.
53	Discontinued procedure, for procedures started but not completed.	Applicable if the procedure is discontinued mid-process, e.g., due to the patient’s worsening condition.
58	Staged or related procedure, for procedures related to a previous one.	Applicable if 58970 is part of a staged IVF process or related to prior procedures.
59	Distinct procedural service to indicate separate from other services on the same day.	Applicable to indicate 58970 is distinct, avoiding bundling with other procedures.
76	Repeat procedure by the same physician on the same day.	Applicable if the same physician repeats 58970 on the same day, though uncommon.
99	Multiple modifiers, for when more than one modifier is needed.	Applicable if multiple circumstances apply, e.g., 59 and 51 together for various procedures.

Reimbursement Guidelines for CPT Code 58970

The reimbursement for CPT code 58970 is more complex when compared with other codes. Below are some guidelines and important points to consider before filing a claim for this code:

Medicare Coverage

The most important thing to note about CPT code 58970 is that Medicare does not provide reimbursement for fertility treatments. This includes IVF and oocyte retrieval. Medicare does not consider these treatments a medical necessity but an elective choice. 

So, as a healthcare provider, you must consult local Medicare Administrative Contractors (MACs) for any regional exceptions. However, such cases and exceptions are rare. The same can be said for private insurance companies. Very few private insurers cover infertility treatments with limited scope. 

Medicaid and Other Programs

Some state Medicaid programs may cover diagnostic infertility services or ovulation-enhancing drugs, but coverage for IVF and oocyte retrieval is limited.

Modifiers

We have already discussed the importance of correct modifier usage in your claims. Without the modifiers, there is a high chance that your claims will be rejected. 

Documentation

Relevant and comprehensive documentation is key to successful claim submission. The documentation must justify the procedure, as no insurance payer will take your word. The attached records should include:

• Patient diagnosis (e.g., ICD-10 codes for infertility).
• Details of the procedure, including method (e.g., transvaginal needle puncture) and outcomes (e.g., number of oocytes retrieved).
• Complications or additional services that were provided.

Supplemental Codes

Since oocyte retrieval is just a small step in the larger infertility treatments, it is often billed alongside other CPT codes. For IVF treatments, the following CPT codes may be used with 58970:

• 89250: Culture of oocyte(s)/embryo(s), less than 4 days.
• 89255: Preparation of embryo for transfer.
• S4011: In vitro fertilization, including incubation and visualization, is often used for broader billing.

Conclusion

CPT code 58970 is essential in fertility treatments. The procedure of oocyte retrieval is the foundation of treatments like IVF.  Many insurance payers, like Medicare, do not reimburse for 58970, and some private insurers that support it require excessive documentation and attention to detail. That’s why healthcare providers need to bill these services accurately. 

You can ensure that by outsourcing OBGYN billing services to professionals. Such medical billing companies hire certified coders with decades of experience in CPT coding and clean claim filing.