Q One of my doctors performed a postcoital analysis of a patient’s mucous due to infertility issues. The physician called it a Sims-Huhner test. How should I code for this service?
A The postcoital test—also known as the Sims-Huhner, or Huhner, test—analyzes the cervical canal after sexual intercourse to determine whether sperm are present and moving. The cervical mucus also may be evaluated to determine its elasticity and drying pattern.
The test is performed 1 to 2 days before ovulation is expected, when the cervical mucus is thin, elastic, and easily penetrable by sperm. Two to 4 hours after the couple has sexual intercourse (without lubricants), a clinician collects the specimen and analyzes it under a microscope.
As it happens, there is a non-CPT code for this procedure: code Q0115, (postcoital direct, qualitative examinations of vaginal or cervical mucous). It is part of the HIPAA-specified code set, and as such may be used to bill for the procedure. Note this is considered a physician-performed microscopy (PPM) procedure, which requires a Clinical Laboratories Improvement Amendments PPM certificate.
A good second choice is the CPT code 89300 (presence and/or motility of sperm including Huhner test [postcoital]), which includes semen analysis. Some infertility physicians I have spoken with recommend using 89300 for the Huhner test even when the semen analysis is not performed. In this scenario, you might consider adding the modifier -52 (reduced services) to be truly “coding accurate.”
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.