WINFertility CPT Codes
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
S4011 In vitro fertilization; including but not limited to identification and incubation of mature
oocytes, fertilization with sperm, incubation of embryo(s), and subseq
uent 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 fertilizati
on procedure cancelled before aspiration, case rate
S4021 In vitro fertilization procedure cancelled after aspiration, case rate
S4022 Assisted oocyte fertilization, case rate
S4028 Microsurgical epididymal sperm aspiration (MESA)
S4035 Stimulated intrauterine insemination (IUI), case rate
S4042 Management of ovulation induction (interpretation of diagnostic tests and studies, non
-
face
-
to
-
face medical management of the patient), per cycle
55870
Electroejaculation
58321
Artificial insemination; intra
-
cervical
5
8322
Artificial insemination; intra
-
uterine
5
8323
Sperm washing for artificial insemination
58970
Follicle puncture for oocyte retrieval, any method
58974
Embryo transfer, intrauterine
5
8976
Gamete, zygote, or embryo intrafallopian transfer, any method
76857
Echography, pelvic (nonobstetric), B
-
scan and/or real time with image documentation;
limited or follow
-
up (eg, for follicles)
76948
Ultrasonic guidance for aspiration of ova, radiological supervision and interpretation
89250
Culture and fertilization of oocyte(s);
89251
Culture and fertilization of oocyte(s); with co
-
culture of embryos
8
9253
Assisted embryo hatching, microtechniques (any method)
89254
Oocyte identification from follicular fluid
89255
Preparation of embryo for transfer (any method)
89268
Insemination of Oocytes
89272
Extended cultures of Oocytes (4
-
7 days)
89280
Assisted oocyte Fertilization, Microtechnique (Less than 10 oocytes)
89281
Assisted oocyte Fertilization, Microtechnique (Greater than 10 oocytes)
89290
Biopsy for PGD; less than or equal to 5 Embryos
89291
Biopsy for PGD; Greater than or equal to 5 Embryos
89398
UNLISTED REPRODUCTIVE MEDICINE LABORATORY PROCEDURE
58540
Hysteroplasty, repair of uterine anomaly (Strassman type)
5
8560
Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
5
8672
Laparoscopy, surgical; with fimbrioplasty
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross
and Blue
Shield Association, an association of independent Blue Cross and Blue Shield Plans.
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