Coding for Long-Acting Reversible Contraception: Billing Quiz Series

Contraceptive Implant Quiz

Scenario 1

Removal

Ms. A. had an implant inserted 2 years ago, and has now decided she would like to become pregnant. Dr. B. provides 15 minutes of prepregnancy counseling and then removes the implant.

How should Dr. B. code for this visit?

Dr. B. reports an E/M service 99401-25 (preventive medicine counseling, 15 minutes) and 11982 (implant removal). The modifier 25 indicates that a significant and separately identifiable E/M service was provided on the same day as a procedure. The diagnoses are Z31.69 (procreative counseling and advice) and Z30.46 (surveillance of implantable subdermal contraceptive [includes removal]).

Scenario 2

Pain at Insertion Site

Ms. C. had an implant inserted 2 weeks ago. She returns to Dr. D’s office with complaints of pain at the insertion site and dizziness. Dr. D examines the insertion site and has a 15 minute discussion with her about whether to keep or remove the implant. Ms. C. decides not to remove the implant at this time, and will return to the office in a month if symptoms continue. The total time for the visit was 20 minutes, including the 15 minutes of counseling.

How should Dr. D. code for this visit?

More than half of the time spent face-to-face with the patient was spent counseling, therefore Dr. D reports E/M code 99213 (established outpatient) based on time. The diagnosis codes are Z30.46 (surveillance of implantable subdermal contraceptive), M79.603 (pain in arm, unspecified), and R42 (dizziness).

Scenario 3

Consultation

Ms. E. is sent to Dr. G by Dr. F. Dr. F asks Dr. G to evaluate whether Ms. E. is a good candidate for the contraceptive implant. Dr. G. performs a detailed history and physical examination with low medical decision making, and has a brief discussion with the patient concerning the benefits and risks of this contraceptive method. He writes a report on his findings and sends it back to Dr. F.

How should Dr. G. code for this visit?

Dr. G. reports an office consultation code 99243. The diagnosis is Z01.818 (pre-procedural examination). A consultation requires that doctor #1 asks doctor #2 for his or her opinion about how a patient should be managed. Both the request and need for the consultation must be documented in the patient’s medical record. Doctor #2 then sends back his or her opinion on how doctor #1 should manage the patient. Note that Medicaid and some private payers do not reimburse for consultation codes. To avoid claim denials, providers should check with payers to determine if they reimburse for consultation codes.

Scenario 4

Removal with Reinsertion

Ms. H. has had an implant for 3 years. She is not planning on having children for 3-5 years, and would like another implant. Dr. I. asks a few questions about any problems she has had with the implant and has Ms. H. sign a consent form. No other issues are discussed, and Dr. I. removes the old implant and inserts a new one all during this one visit.

How should Dr. I. code for this visit?

Dr. I. reports CPT code 11983 (implant removal with reinsertion) and a supply code of J7307 for the implant. The diagnosis is Z30.46 (surveillance of implantable subdermal contraceptive [includes reinsertion]). No E/M services are reported for the brief discussion with the patient prior to the removal and reinsertion procedures.

Scenario 5

Post-Abortion Insertion

Ms. J., a new patient of Dr. K., is 18 years old. Ms. J comes into the office stating she is 12 weeks pregnant and denies pain or cramping. She requests an abortion. Ms. J. and Dr. K. discuss the procedure and contraceptive options. After a discussion of the benefits and risks of a number of different contraceptive methods and a brief physical examination to confirm the pregnancy, a D&C is scheduled for the next day. An implant will also be inserted at this time. This initial visit lasted 20 minutes, including 15 minutes spent counseling. The content of the counseling is documented in the medical record. The next day, Ms. J. comes to the outpatient center for the abortion. Dr. K. takes her temperature and blood pressure and asks if there are any changes in her condition. Dr. K. performs the D&C and inserts a contraceptive implant into Ms. J’s arm.

How should Dr. K. code for the office visit and outpatient procedures?

The table below summarizes codes reported for this scenario. For the initial office visit, Dr. K. reports an E/M service. The documentation shows that more than 50% of the time spent face-to-face with the patient was spent counseling Ms. J. on contraceptive choices. Therefore, Dr. K. reports E/M code 99202-57 (new patient, typical time of 20 minutes). Modifier 57 indicates that a decision for surgery was made during this visit. Note that if the initial visit had been more than 1 day before the surgery, the modifier is not needed. The diagnosis code is Z30.017 (initial prescription of implantable subdermal contraceptive). Code Z3A.12 (12 weeks gestation of pregnancy) might also be used, but is not required. For the outpatient center visit, Dr. K reports codes 59840 (D&C), 11981-51 (implant insertion), and HCPCS supply code J7307 for the implant. Note that modifier 51 (multiple procedures) is added to the lesser procedure. The E/M services (taking her temperature, etc.) are part of the preoperative care and not reported separately. The diagnosis codes are Z33.2 (elective termination of pregnancy), Z64.0 (problems related to unwanted pregnancy), and Z30.017 (initial prescription of implantable subdermal contraceptive [includes insertion]).

Scenario 6

Immediate Postpartum Insertion

Ms. L. is a 28 year old G4P3 patient of Dr. M. She delivered all previous pregnancies vaginally. During antepartum care, counseling was provided about the benefits and risks of all contraceptive methods, and Ms. L. expressed desire to use a contraceptive implant postpartum. The decision was made to have the implant inserted immediately after delivery. At 39 weeks 0 days following an uncomplicated antepartum course, Ms. L. presents to the hospital. Dr. M. delivers Ms. L.’s fourth child vaginally and immediately inserts a contraceptive implant. She is scheduled for her routine six week postpartum visit.

How should Dr. M. code for the global obstetric care of the postpartum implant insertion?

The table below summarizes the codes reported for this scenario. For obstetric services, Dr. M. reports global CPT code 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) with outcome of delivery diagnosis codes O80 (full-term uncomplicated delivery), Z37.0 (single live birth), and Z3A.39 (39 weeks gestation of pregnancy). For the implant, Dr. M. reports 11981-51 (insertion) and J7307 (etonogestrel [contraceptive] implant system, including implant and supplies) supply code. Since the implant was inserted immediately after delivery, the modifier 51 (multiple procedures) is added to the lesser procedure. No E/M services code is reported since counseling on contraception was provided during antepartum care visit and included into the global code. The diagnosis code is Z30.017 (initial prescription of implantable subdermal contraceptive [includes insertion]). Note that coverage of immediate postpartum LARC varies by payer and state. A list of states with published guidance on Medicaid reimbursement for postpartum LARC can be found at www.acog.org/IPPLARCmedicaid. To avoid claim denials, providers should check with payers to determine if they reimburse for immediate postpartum LARC and how to bill appropriately to ensure reimbursement.