36C24418Q9641-002.xlsx

XLSX spreadsheet 201 KB Posted Aug 24, 2018

Attached to: In-vitro Fertilization (IVF)/ Assisted Reproductive Technolo Federal contract opportunity
Solicitation number: 36C24418Q9641
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 4

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36C24418Q9641 D.1 Copy of Infertility-ART-IVF Price Schedule.xlsx

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36C24418Q9641_0001.docx	DOCX document	Dec 9, 2018
36C24418Q9641-003.xlsx	XLSX spreadsheet	Aug 24, 2018
36C24418Q9641-004.xlsx	XLSX spreadsheet	Aug 24, 2018
36C24418Q9641-005.pdf	PDF	Aug 24, 2018
36C24418Q9641-002.xlsx	XLSX spreadsheet	Aug 24, 2018
36C24418Q9641-001.docx	DOCX document	Aug 24, 2018
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36C24418Q9641-000.docx	DOCX document	Aug 24, 2018
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Femal price schedule Episode of Care Infertility-ART-IVF Female 1.0.1

Included services	CPT/HCPCS code	Short Description	Unit	Price
Initial outpatient evaluation and treatment for infertility	99201 - 99215	Evaluation & Management	EA
Six visits for diagnostic imaging relevant to the patient complaint/condition
Twelve visits for diagnostic studies, lab and pathology services relevant to the patient complaint/condition
Procedures to include: Ovarian stimulation medications (oral and/or injectable), oocyte harvesting, In-vitro insemination (IVF) including intra-Cytoplasmic Sperm Injection (ICSI), embryo culture, fresh or frozen embryo transfer, cryopreservation techniques and genetic testing as indicated. Ovarian stimulation will require multiple labs and ultrasounds.
Maximum of six (6) attempts to achieve 3 complete IVF cycles in a lifetime of the eligible SC Veteran. A cycle is defined as transfer of 1 or more embryos. Transfer of a frozen embryo would be considered a cycle.

	Other services found through Previous HIMS Review
		00840	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified	EA
		00842	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; amniocentesis	EA
		10021	Fine needle aspiration; without imaging guidance	EA
		10022	Fine needle aspiration; with imaging guidance	EA
		36415	Collection of venous blood by venipuncture	EA
		58120	Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical	EA
		58140	Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach	EA
		58145	Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach	EA
		58146	Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach	EA
		58321	Artificial insemination; intra-cervical	EA
		58322	Artificial insemination; intra-uterine	EA
		58323	Sperm washing for artificial insemination	EA
		58340	Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography	EA
		58345	Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography	EA
		58350	Chromotubation of oviduct, including materials	EA
		58540	Hysteroplasty, repair of uterine anomaly (Strassman type)	EA
		58545	Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas	EA
		58546	Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams	EA
		58555	Hysteroscopy, diagnostic (separate procedure)	EA
		58558	Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C	EA
		58559	Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)	EA
		58560	Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)	EA
		58561	Hysteroscopy, surgical; with removal of leiomyomata	EA
		58662	Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method	EA
		58670	Laparoscopy, surgical; with fulguration of oviducts (with or without transection)	EA
		58672	Laparoscopy, surgical; with fimbrioplasty	EA
		58673	Laparoscopy, surgical; with salpingostomy (salpingoneostomy)	EA
		58679	Unlisted laparoscopy procedure, oviduct, ovary	EA
		58700	Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)	EA
		58740	Lysis of adhesions (salpingolysis, ovariolysis)	EA
		58752	Tubouterine implantation	EA
		58760	Fimbrioplasty	EA
		58770	Salpingostomy (salpingoneostomy)	EA
		58800	Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); vaginal approach	EA
		58805	Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); abdominal approach	EA
		58920	Wedge resection or bisection of ovary, unilateral or bilateral	EA
		58970	Follicle puncture for oocyte retrieval, any method	EA
		58974	Embryo transfer, intrauterine	EA
		58976	Gamete, zygote, or embryo intrafallopian transfer, any method
EA
		58999	Unlisted procedure, female genital system (nonobstetrical)	EA
		59344	Storage (per year); reproductive tissue, testicular/ovarian	EA
		59425	Antepartum care only; 4-6 visits	EA
		59426	Antepartum care only; 7 or more visits	EA
		59510	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care	EA
		59610	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery	EA
		59618	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery	EA
		59820	Treatment of missed abortion, completed surgically; first trimester	EA
		59840	Induced abortion, by dilation and curettage	EA
		69990	Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)	EA
		74740	Hysterosalpingography, radiological supervision and interpretation	EA
		74742	Transcervical catheterization of fallopian tube, radiological supervision and interpretation	EA
		76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation	EA
		76700	Ultrasound, abdominal, real time with image documentation; complete	EA
		76812	Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)	EA
		76815	Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses	EA
		76816	Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a prev	EA
		76830	Ultrasound, transvaginal	EA
		76831	Saline infusion sonohysterography (SIS), including color flow Doppler, when performed	EA
		76844	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation	EA
		76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete	EA
		76857	Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles)	EA
		76941	Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation	EA
		76942	Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation	EA
		76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation	EA
		80415	Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on three pooled blood samples)	EA
		80426	Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4)	EA
		81224	CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; intron 8 poly-T analysis (e.g., male infertility)	EA
		82670	Estradiol	EA
		83001	Gonadotropin; follicle stimulating hormone (FSH)	EA
		83002	Gonadotropin; luteinizing hormone (LH)	EA
		83498	Hydroxyprogesterone, 17-d	EA
		83520	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified	EA
		84144	Progesterone	EA
		84146	Prolactin	EA
		84443	Thyroid stimulating hormone (TSH)	EA
		84702	Gonadotropin, chorionic (hCG); quantitative	EA
		84830	Ovulation tests, by visual color comparison methods for human luteinizing hormone	EA
		88182	Flow cytometry, cell cycle or DNA analysis	EA
		88248	Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes (e.g., for ataxia telangiectasia, Fanconi anemia, fragile X)	EA
		88261	Chromosome analysis; count 5 cells, 1 karyotype, with banding	EA
		88262	Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding	EA
		88263	Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding	EA
		88273	Molecular cytogenetics; chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions)	EA
		88280	Chromosome analysis; additional karyotypes, each study	EA
		88283	Chromosome analysis; additional specialized banding technique (e.g., NOR, C-banding)	EA
		88285	Chromosome analysis; additional cells counted, each study	EA
		89240	Unlisted miscellaneous pathology test	EA
		89250	Culture of oocyte(s)/embryo(s), less than 4 days;	EA
		89251	Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos	EA
		89253	Assisted embryo hatching, microtechniques (any method)	EA
		89254	Oocyte identification from follicular fluid	EA
		89255	Preparation of embryo for transfer (any method)	EA
		89258	Cryopreservation; embryo(s)	EA
		89268	Insemination of oocytes	EA
		89272	Extended culture of oocyte(s)/embryo(s), 4-7 days	EA
		89280	Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes	EA
		89281	Assisted oocyte fertilization, microtechnique; greater than 10 oocytes	EA
		89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos	EA
		89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos	EA
		89330	Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test	EA
		89342	Storage (per year); embryo(s)	EA
		89343	Storage (per year); sperm/semen	EA
		89344	Storage (per year); reproductive tissue, testicular/ovarian	EA
		89346	Storage (per year); oocyte(s)	EA
		89349	Storage (per year); sperm/semen	EA
		89352	Thawing of cryopreserved; embryo(s)	EA
		89354	Thawing of cryopreserved; reproductive tissue, testicular/ovarian	EA
		99000	Handling and/or conveyance of specimen for transfer from the office to a laboratory	EA
		99070	Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)	EA
		99078	Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions)	EA
		J0725	Injection, chorionic gonadotropin, per 1,000 USP units	EA
		J3355	Injection, urofollitropin, 75 IU	EA
		S0122	Injection, menotropins, 75 IU	EA
		S0126	Injection, follitropin alfa, 75 IU	EA
		S0128	Injection, follitropin beta, 75 IU	EA
		S0132	Injection, ganirelix acetate 250 mcg	EA
		S3600	Stat laboratory request (situations other than s3601)	EA
		S3655	Antisperm antibodies test (immunobead)	EA
		S4011	In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development	EA
		S4013	Complete cycle, gamete intrafallopian transfer (GIFT), case rate	EA
		S4014	Complete cycle, zygote intrafallopian transfer (ZIFT), case rate	EA
		S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate	EA
		S4016	Frozen in vitro fertilization cycle, case rate	EA
		S4017	Incomplete cycle, treatment cancelled prior to stimulation, case rate	EA
		S4018	Frozen embryo transfer procedure cancelled before transfer, case rate	EA
		S4020	In vitro fertilization procedure cancelled before aspiration, case rate	EA
		S4021	In vitro fertilization procedure cancelled after aspiration, case rate	EA
		S4022	Assisted oocyte fertilization, case rate	EA
		S4023	Donor egg cycle, incomplete, case rate	EA
		S4025	Donor services for in vitro fertilization (sperm or embryo), case rate	EA
		S4026	Procurement of donor sperm from sperm bank	EA
		S4027	Storage of previously frozen embryos	EA
		S4035	Stimulated intrauterine insemination (IUI), case rate	EA
		S4037	Cryopreserved embryo transfer, case rate	EA
		S4042	Management of ovulation induction (interpretation of diagnostic tests and studies, non face-to-face medical management of the patient), per cycle	EA

Male Price Schedule Episode of Care Infertility-ART-IVF Male 1.0.1

Included services	CPT/HCPCS code	Short Description	Unit	Cost
1. Initial outpatient evaluation and treatment for infertility	99201 - 99215	Evaluation & Management	EA
2. 10 visits for diagnostic imaging/studies, lab and pathology services relevant to the patient complaint/condition
3. Procedures to obtain viable sperm for reproductive efforts to include: surgical procedures, sperm extraction techniques
4. Cryopreservation techniques
5. Sperm genetic testing related to sperm function and viability
6. Please see attached consultation for number of cycles approved.

Other services found through Previous HIMS Review	CPT/HCPCS code	Short Description
	36415	Collection of venous blood by venipuncture	EA
	58323	Sperm washing for artificial insemination	EA
	52402	Cystourethroscopy with transurethral resection or incision of ejaculatory ducts	EA
	54500	Biopsy of testis, needle (separate procedure)	EA
	54505	Biopsy of testis, incisional (separate procedure)	EA
	54800	Biopsy of epididymis, needle	EA
	54900	Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral	EA
	54901	Epididymovasostomy, anastomosis of epididymis to vas deferens; bilatera	EA
	55200	Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)	EA
	55300	Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral	EA
	55530	Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)	EA
	55535	Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach	EA
	55540	Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair	EA
	55550	Laparoscopy, surgical, with ligation of spermatic veins for varicocele	EA
	55870	Electroejaculation	EA
	58323	Sperm washing for artificial insemination	EA
	74440	Vasography, vesiculography, or epididymography, radiological supervision and interpretation	EA
	76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation	EA
	76870	Ultrasound, scrotum and contents	EA
	76872	Ultrasound, transrectal	EA
	81224	CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; intron 8 poly-T analysis (e.g., male infertility)	EA
	84144	Progesterone	EA
	84702	Gonadotropin, chorionic (hCG); quantitative	EA
	89257	Sperm identification from aspiration (other than seminal fluid)	EA
	89259	Cryopreservation; sperm	EA
	89260	Sperm isolation; simple prep (eg, sperm wash and swim-up) for insemination or diagnosis with semen analysis	EA
	89261	Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis	EA
	89264	Sperm identification from testis tissue, fresh or cryopreserved	EA
	89280	Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes	EA
	89281	Assisted oocyte fertilization, microtechnique; greater than 10 oocytes	EA
	89300	Semen analysis; presence and/or motility of sperm including Huhner test (post coital)	EA
	89310	Semen analysis; motility and count (not including Huhner test)	EA
	89320	Semen analysis; volume, count, motility, and differential	EA
	89321	Semen analysis; sperm presence and motility of sperm, if performed	EA
	89322	Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger)	EA
	89325	Sperm antibodies	EA
	89329	Sperm evaluation; hamster penetration test	EA
	89330	Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test	EA
	89331	Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)	EA
	89343	Storage (per year); sperm/semen	EA
	89343	Storage (per year); sperm/semen	EA
	89344	Storage (per year); reproductive tissue, testicular/ovarian	EA
	89349	Storage (per year); sperm/semen	EA
	89353	Thawing of cryopreserved; sperm/semen, each aliquot	EA
	89354	Thawing of cryopreserved; reproductive tissue, testicular/ovarian	EA
	89356	Thawing of cryopreserved; oocytes, each aliquot	EA
	99000	Handling and/or conveyance of specimen for transfer from the office to a laboratory	EA
	99070	Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)	EA
	99078	Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions)	EA
	G0027	Semen analysis; presence and/or motility of sperm excluding Huhner	EA
	S3600	Stat laboratory request (situations other than s3601)	EA
	S3655	Antisperm antibodies test (immunobead)	EA
	S4011	In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development	EA
	S4022	Assisted oocyte fertilization, case rate	EA
	S4025	Donor services for in vitro fertilization (sperm or embryo), case rate	EA
	S4026	Procurement of donor sperm from sperm bank	EA
	S4028	Microsurgical epididymal sperm aspiration (MESA)	EA
	S4030	Sperm procurement and cryopreservation services; initial visit	EA
	S4031	Sperm procurement and cryopreservation services; subsequent visit	EA
	S4035	Stimulated intrauterine insemination (IUI), case rate	EA

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