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Coding and Reimbursement Guide
Fallopian Tube, Uterine Cavity, and Pelvic Evaluation
CPT® Code
Description
RVU1
National Average Medicare Rate1
Use only one
76856
Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
3.75
$127.64
76830
Transvaginal ultrasound,
nonobstetric
3.79
$129.00
 
58340
Catheterization and introduction of saline
or contrast material for saline infusion
sonohysterography (SIS) or hysterosalpingography
3.58
$121.85
Coded together
76831
Saline infusion sonohysterography (SIS)
3.83
$130.36
76376
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality
1.96
$66.71
 
74740
Hysterosalpingography, radiological supervision
and interpretation
(For introduction of saline or contrast for hysterosalpingography, see 58340)
2.38
$81.01

ICD Code
Description
628
Infertility, female
Includes: primary and secondary sterility
628.2
Of tubal origin
Infertility associated with congenital anomaly of tube
Tubal: block, occlusion, stenosis
628.9
Of unspecified origin

V Code
Description
26.2
Investigation and testing
26.21
Fertility testing
Fallopian insufflation

1. Physician Relative Value Units (RVUs) are based on the Medicare 2012 Physician Fee Schedule effective January 1, 2012. National Average Medicare Rates are based on these RVUs and account for the work RVU adjustment completed by CMS for Medical budget neutrality purposes. The 2012 Conversion factor is $34.0376. Actual payment to physician will vary based on geographic location. Payment for a given procedure in a given locality is available in the Medicare Physician Fee Schedule Look-up file posted in the Physician Center of the CMS website.    

DISCLAIMER:  The information contained in this guide is provided for information purposes only and represents no statement, promise or guarantee by Femasys Inc. concerning levels of reimbursement, the appropriateness of the codes, or that reimbursement will be made.  It is the provider’s responsibility to determine and submit the appropriate codes and modifiers for any service, supply, or procedure rendered. Consult with your payor organizations with regard to local reimbursement policies and specific coding guide.

Current Procedural Terminology (CPT) is copyright 2009 American Medical Association. All rights reserved.
CPT® is a trademark of the AMA. 
No fee schedules, basic units, relative values, or related listings are included in CPT.  The AMA assumes no liability for the data contained herein. 

For questions contact customerservice@femasys.com or +1.877.336.2562


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