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2025 ICD-10-CM code Z31.41

Encounter for fertility testing.

This is a Z code, and as such it can't be the primary diagnosis code.A code describing the reason for the encounter should also be listed as the primary code.This code is exempt from the Present on Admission (POA) reporting requirement.

Medical necessity for fertility testing is established when a couple has been unable to conceive naturally after a reasonable period (usually 12 months for women under 35, or 6 months for women 35 and older) or when there is a known medical condition affecting fertility.

The clinician is responsible for ordering and interpreting the fertility tests, counseling the patient on the results, and recommending next steps in their fertility journey.

In simple words: This code is used when someone visits a healthcare provider specifically for fertility testing, such as checking if the fallopian tubes are open or evaluating sperm count.

This code is used for encounters with health services for fertility testing, which includes fallopian tube patency tests and sperm count analysis.It excludes postvasectomy sperm counts (Z30.8) and complications associated with artificial fertilization (N98.-), female infertility (N97.-), and male infertility (N46.-).

Example 1: A 35-year-old female presents to her gynecologist for fertility testing after trying to conceive naturally for 12 months without success., A 40-year-old male visits a urologist for a semen analysis as part of a fertility evaluation for him and his partner., A couple experiencing infertility goes to a fertility clinic, where both the male and female undergo testing.The female undergoes a fallopian tube patency test, and the male provides a semen sample for analysis.

Documentation should include the reason for fertility testing, the specific tests performed (e.g., semen analysis, fallopian tube patency test), the results of the tests, and any recommendations or follow-up plans.

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