36C24418Q9641-003.xlsx

XLSX spreadsheet 136 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.2 Infertility-ART-IVF Female SEOC 1.0.1 Final.xlsx

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36C24418Q9641_0001.docx	DOCX document	Dec 9, 2018
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36C24418Q9641-005.pdf	PDF	Aug 24, 2018
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SEOC Template VHA Office of Community Care – Standardized Episode of Care

Infertility Care

ART-IVF Female SEOC 1.0.1

SEOC ID: INF_ART-IVF_FEMALE_1.0.1

Description: This authorization covers services associated with all medical care listed below for the referred condition. Services can only be provided through the Patient Centered Community Care (PC3) contract.

Duration: 365 days

Frequency: As clinically indicated

Procedural Overview

1. Initial outpatient evaluation and treatment for infertility

2. Six (6) visits for diagnostic imaging relevant to the referred condition

3. Twelve (12) visits for diagnostic studies, lab and pathology services relevant to the referred condition

4. 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

5. Maximum of six (6) attempts to achieve three (3) complete IVF cycles in a lifetime of the eligible service-connected Veteran. A cycle is defined as transfer of one (1) or more embryos. Transfer of a frozen embryo would be considered a cycle.

**Additional consultations needed relevant to the patient complaint/condition require VA review and approval.

**DME, prosthetics and orthotics orders must be submitted to the local VA facility prosthetics department for provision.

**All routine medications must be faxed/sent to the VA to be dispensed by the VA.

Urgent/emergent prescriptions can be provided for a 14-day supply only.

The Veteran will be required to pay out of pocket for any urgent/emergent medications and

can submit a reimbursement request to their local VA facility.

CPT Crosswalk Episode of Care Infertility-ART-IVF Female 1.0.1

Included services	CPT/HCPCS code	Short Description
Initial outpatient evaluation and treatment for infertility	99201 - 99215	Evaluation & Management
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
	00842	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; amniocentesis
	10021	Fine needle aspiration; without imaging guidance
	10022	Fine needle aspiration; with imaging guidance
	36415	Collection of venous blood by venipuncture
	58120	Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical
	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
	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
	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
	58321	Artificial insemination; intra-cervical
	58322	Artificial insemination; intra-uterine
	58323	Sperm washing for artificial insemination
	58340	Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
	58345	Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography
	58350	Chromotubation of oviduct, including materials
	58540	Hysteroplasty, repair of uterine anomaly (Strassman type)
	58545	Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas
	58546	Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams
	58555	Hysteroscopy, diagnostic (separate procedure)
	58558	Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C
	58559	Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
	58560	Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
	58561	Hysteroscopy, surgical; with removal of leiomyomata
	58662	Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
	58670	Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
	58672	Laparoscopy, surgical; with fimbrioplasty
	58673	Laparoscopy, surgical; with salpingostomy (salpingoneostomy)
	58679	Unlisted laparoscopy procedure, oviduct, ovary
	58700	Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
	58740	Lysis of adhesions (salpingolysis, ovariolysis)
	58752	Tubouterine implantation
	58760	Fimbrioplasty
	58770	Salpingostomy (salpingoneostomy)
	58800	Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); vaginal approach
	58805	Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); abdominal approach
	58920	Wedge resection or bisection of ovary, unilateral or bilateral
	58970	Follicle puncture for oocyte retrieval, any method
	58974	Embryo transfer, intrauterine
	58976	Gamete, zygote, or embryo intrafallopian transfer, any method

58999	Unlisted procedure, female genital system (nonobstetrical)
59344	Storage (per year); reproductive tissue, testicular/ovarian
59425	Antepartum care only; 4-6 visits
59426	Antepartum care only; 7 or more visits
59510	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
59610	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery
59618	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery
59820	Treatment of missed abortion, completed surgically; first trimester
59840	Induced abortion, by dilation and curettage
69990	Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)
74740	Hysterosalpingography, radiological supervision and interpretation
74742	Transcervical catheterization of fallopian tube, radiological supervision and interpretation
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
76700	Ultrasound, abdominal, real time with image documentation; complete
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)
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
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
76830	Ultrasound, transvaginal
76831	Saline infusion sonohysterography (SIS), including color flow Doppler, when performed
76844	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
76857	Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles)
76941	Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation
76942	Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation
76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
80415	Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on three pooled blood samples)
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)
81224	CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; intron 8 poly-T analysis (e.g., male infertility)
82670	Estradiol
83001	Gonadotropin; follicle stimulating hormone (FSH)
83002	Gonadotropin; luteinizing hormone (LH)
83498	Hydroxyprogesterone, 17-d
83520	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified
84144	Progesterone
84146	Prolactin
84443	Thyroid stimulating hormone (TSH)
84702	Gonadotropin, chorionic (hCG); quantitative
84830	Ovulation tests, by visual color comparison methods for human luteinizing hormone
88182	Flow cytometry, cell cycle or DNA analysis
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)
88261	Chromosome analysis; count 5 cells, 1 karyotype, with banding
88262	Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding
88263	Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding
88273	Molecular cytogenetics; chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions)
88280	Chromosome analysis; additional karyotypes, each study
88283	Chromosome analysis; additional specialized banding technique (e.g., NOR, C-banding)
88285	Chromosome analysis; additional cells counted, each study
89240	Unlisted miscellaneous pathology test
89250	Culture of oocyte(s)/embryo(s), less than 4 days;
89251	Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos
89253	Assisted embryo hatching, microtechniques (any method)
89254	Oocyte identification from follicular fluid
89255	Preparation of embryo for transfer (any method)
89258	Cryopreservation; embryo(s)
89268	Insemination of oocytes
89272	Extended culture of oocyte(s)/embryo(s), 4-7 days
89280	Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
89281	Assisted oocyte fertilization, microtechnique; greater than 10 oocytes
89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos
89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos
89330	Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
89342	Storage (per year); embryo(s)
89343	Storage (per year); sperm/semen
89344	Storage (per year); reproductive tissue, testicular/ovarian
89346	Storage (per year); oocyte(s)
89349	Storage (per year); sperm/semen
89352	Thawing of cryopreserved; embryo(s)
89354	Thawing of cryopreserved; reproductive tissue, testicular/ovarian
99000	Handling and/or conveyance of specimen for transfer from the office to a laboratory
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)
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)
J0725	Injection, chorionic gonadotropin, per 1,000 USP units
J3355	Injection, urofollitropin, 75 IU
S0122	Injection, menotropins, 75 IU
S0126	Injection, follitropin alfa, 75 IU
S0128	Injection, follitropin beta, 75 IU
S0132	Injection, ganirelix acetate 250 mcg
S3600	Stat laboratory request (situations other than s3601)
S3655	Antisperm antibodies test (immunobead)
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
S4013	Complete cycle, gamete intrafallopian transfer (GIFT), case rate
S4014	Complete cycle, zygote intrafallopian transfer (ZIFT), case rate
S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016	Frozen in vitro fertilization cycle, case rate
S4017	Incomplete cycle, treatment cancelled prior to stimulation, case rate
S4018	Frozen embryo transfer procedure cancelled before transfer, case rate
S4020	In vitro fertilization procedure cancelled before aspiration, case rate
S4021	In vitro fertilization procedure cancelled after aspiration, case rate
S4022	Assisted oocyte fertilization, case rate
S4023	Donor egg cycle, incomplete, case rate
S4025	Donor services for in vitro fertilization (sperm or embryo), case rate
S4026	Procurement of donor sperm from sperm bank
S4027	Storage of previously frozen embryos
S4035	Stimulated intrauterine insemination (IUI), case rate
S4037	Cryopreserved embryo transfer, case rate
S4042	Management of ovulation induction (interpretation of diagnostic tests and studies, non face-to-face medical management of the patient), per cycle

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