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HCPCS Range ASSORTED OBSTETRICAL AND FERTILITY SERVICES

• 1 Interim labor facility global (labor occurring but not resulting in delivery) ( S4005 )

• 2 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 ( S4011 )

• 3 Complete cycle, gamete intrafallopian transfer (GIFT), case rate ( S4013 )

• 4 Complete cycle, zygote intrafallopian transfer (ZIFT), case rate ( S4014 )

• 5 Complete in vitro fertilization cycle, not otherwise specified, case rate ( S4015 )

• 6 Frozen in vitro fertilization cycle, case rate ( S4016 )

• 7 Incomplete cycle, treatment cancelled prior to stimulation, case rate ( S4017 )

• 8 Frozen embryo transfer procedure cancelled before transfer, case rate ( S4018 )

• 9 In vitro fertilization procedure cancelled before aspiration, case rate ( S4020 )

• 10 In vitro fertilization procedure cancelled after aspiration, case rate ( S4021 )

• 11 Assisted oocyte fertilization, case rate ( S4022 )

• 12 Donor egg cycle, incomplete, case rate ( S4023 )

• 13 Donor services for in vitro fertilization (sperm or embryo), case rate ( S4025 )

• 14 Procurement of donor sperm from sperm bank ( S4026 )

• 15 Storage of previously frozen embryos ( S4027 )

• 16 Microsurgical epididymal sperm aspiration (MESA) ( S4028 )

• 17 Sperm procurement and cryopreservation services; initial visit ( S4030 )

• 18 Sperm procurement and cryopreservation services; subsequent visit ( S4031 )

• 19 Stimulated intrauterine insemination (IUI), case rate ( S4035 )

• 20 Cryopreserved embryo transfer, case rate ( S4037 )

• 21 Monitoring and storage of cryopreserved embryos, per 30 days ( S4040 )

• 22 Management of ovulation induction (interpretation of diagnostic tests and studies, non-face-to-face medical management of the patient), per cycle ( S4042 )

• 23 Insertion of levonorgestrel-releasing intrauterine system ( S4981 )

• 24 Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies ( S4989 )

• 25 Penile contracture device, manual, greater than 3 lbs traction force ( S4988 )