36C24418Q9641-004.xlsx
XLSX spreadsheet 132 KB Posted
- Attached to
- In-vitro Fertilization (IVF)/ Assisted Reproductive Technolo Federal contract opportunity
- Solicitation number
- 36C24418Q9641
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36C24418Q9641 D.3 Infertility-ART-IVF Male SEOC 1.1.1 Final.xlsx
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| File | Type | Posted |
|---|---|---|
| 36C24418Q9641_0001.docx | DOCX document | |
| 36C24418Q9641-003.xlsx | XLSX spreadsheet | |
| 36C24418Q9641-004.xlsx | XLSX spreadsheet | |
| 36C24418Q9641-006.xlsx | XLSX spreadsheet | |
| 36C24418Q9641-005.pdf | ||
| 36C24418Q9641-002.xlsx | XLSX spreadsheet | |
| 36C24418Q9641-001.docx | DOCX document | |
| 36C24418Q9641-005.pdf | ||
| 36C24418Q9641-003.xlsx | XLSX spreadsheet | |
| 36C24418Q9641-006.xlsx | XLSX spreadsheet | |
| 36C24418Q9641-001.docx | DOCX document | |
| 36C24418Q9641-002.xlsx | XLSX spreadsheet | |
| 36C24418Q9641-000.docx | DOCX document | |
| 36C24418Q9641-000.docx | DOCX document |
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SEOC Template VHA Office of Community Care – Standardized Episode of Care
| Medical Specialty Care |
| IVF Male SEOC 1.1.1 |
| SEOC ID: INF_ART-IVF_MALE_1.1.1 |
| 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. Ten (10) visits for diagnostic imaging/studies, lab and pathology services relevant to the |
| referred 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. |
| **Additional consultations needed relevant to the patient complaint/condition require VA review and approval. |
| **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 Male 1.0.1
| Included services | CPT/HCPCS code | Short Description |
| 1. Initial outpatient evaluation and treatment for infertility | 99201 - 99215 | Evaluation & Management |
| 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 | |
| 58323 | Sperm washing for artificial insemination | |
| 52402 | Cystourethroscopy with transurethral resection or incision of ejaculatory ducts | |
| 54500 | Biopsy of testis, needle (separate procedure) | |
| 54505 | Biopsy of testis, incisional (separate procedure) | |
| 54800 | Biopsy of epididymis, needle | |
| 54900 | Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral | |
| 54901 | Epididymovasostomy, anastomosis of epididymis to vas deferens; bilatera | |
| 55200 | Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) | |
| 55300 | Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral | |
| 55530 | Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) | |
| 55535 | Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach | |
| 55540 | Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair | |
| 55550 | Laparoscopy, surgical, with ligation of spermatic veins for varicocele | |
| 55870 | Electroejaculation | |
| 58323 | Sperm washing for artificial insemination | |
| 74440 | Vasography, vesiculography, or epididymography, 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 | |
| 76870 | Ultrasound, scrotum and contents | |
| 76872 | Ultrasound, transrectal | |
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; intron 8 poly-T analysis (e.g., male infertility) | |
| 84144 | Progesterone | |
| 84702 | Gonadotropin, chorionic (hCG); quantitative | |
| 89257 | Sperm identification from aspiration (other than seminal fluid) | |
| 89259 | Cryopreservation; sperm | |
| 89260 | Sperm isolation; simple prep (eg, sperm wash and swim-up) for insemination or diagnosis with semen analysis | |
| 89261 | Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis | |
| 89264 | Sperm identification from testis tissue, fresh or cryopreserved | |
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes | |
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes | |
| 89300 | Semen analysis; presence and/or motility of sperm including Huhner test (post coital) | |
| 89310 | Semen analysis; motility and count (not including Huhner test) | |
| 89320 | Semen analysis; volume, count, motility, and differential | |
| 89321 | Semen analysis; sperm presence and motility of sperm, if performed | |
| 89322 | Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger) | |
| 89325 | Sperm antibodies | |
| 89329 | Sperm evaluation; hamster penetration test | |
| 89330 | Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test | |
| 89331 | Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) | |
| 89343 | Storage (per year); sperm/semen | |
| 89343 | Storage (per year); sperm/semen | |
| 89344 | Storage (per year); reproductive tissue, testicular/ovarian | |
| 89349 | Storage (per year); sperm/semen | |
| 89353 | Thawing of cryopreserved; sperm/semen, each aliquot | |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian | |
| 89356 | Thawing of cryopreserved; oocytes, each aliquot | |
| 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) | |
| G0027 | Semen analysis; presence and/or motility of sperm excluding Huhner | |
| 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 | |
| S4022 | Assisted oocyte fertilization, case rate | |
| S4025 | Donor services for in vitro fertilization (sperm or embryo), case rate | |
| S4026 | Procurement of donor sperm from sperm bank | |
| S4028 | Microsurgical epididymal sperm aspiration (MESA) | |
| S4030 | Sperm procurement and cryopreservation services; initial visit | |
| S4031 | Sperm procurement and cryopreservation services; subsequent visit | |
| S4035 | Stimulated intrauterine insemination (IUI), case rate |
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