Coding for Long-Acting Reversible Contraception: Billing Quiz Series

Intrauterine Device Quiz

Scenario 1

Removal and Insertion

Ms. N. had a 52 mg, 5-year duration levonorgestrel IUD inserted six years ago. She sees Dr. O. for removal of the IUD and insertion of a new one. Ms. N. tells Dr. O. that she has had no problems with the IUD over the last few years. The nurse takes her vital signs. Dr. O. removes the IUD and inserts a new 52 mg, 5 year duration levonorgestrel IUD.

How Should Dr. O. code for the visit?

Dr. O. reports codes 58301 (removal) and 58300-51 (insertion) and J7298 (levonorgestrel-releasing intrauterine contraceptive system [Mirena®], 52 mg [5 year duration]) for the IUD. The diagnosis code is Z30.433 (removal and reinsertion of IUD). Note that modifier 51 (multiple procedures) is added to the lesser procedure. No E/M services code is reported since the brief discussion and taking of vital signs is not a significant service. To avoid claim denials, providers should check with payers to determine if they reimburse for both removal and reinsertion and how to bill appropriately to ensure reimbursement. 

Scenario 2

Post-Miscarriage Insertion

Ms. P. is 10 weeks pregnant and comes in to see Dr. Q. because of heavy vaginal bleeding. She had seen Dr. Q. previously for obstetric care. Dr. Q. performs an examination, asks some questions, and performs a limited ultrasound. He decides Ms. P. is having a miscarriage and counsels her for 25 minutes about the incidence, possible causes, and prognosis of miscarriage, and suggests immediate treatment. Ms. P also requests insertion of a copper IUD. Dr. Q. completes the miscarriage surgically and inserts a copper IUD during this visit. The total time for the visit is 35 minutes.

How should Dr. Q. code for these services?

Dr. Q. reports codes 76817 (transvaginal ultrasound), 59812 (incomplete abortion completed surgically) and 58300-51 (IUD insertion). HCPCS code J7300 (intrauterine copper contraceptive [Paragard®] [10 year duration]) is reported for the IUD supply. The diagnosis codes are O03.39 (spontaneous abortion with other specified complications, incomplete) and Z30.430 (insertion of IUD). More than half of the time spent face-to-face with the patient was spent counseling, therefore Dr. Q. reports E/M code 99215 (typical time of 40 minutes) with a modifier 25 (significant, separately identifiable E/M service). The topics discussed must be documented. If the miscarriage was complete (requiring no surgical intervention), Dr. Q. would have reported an E/M service with a modifier 25 (significant, separately identifiable E/M service), plus 58300 for the IUD insertion. 

Scenario 3

IUD Removal and Implant Insertion

Ms. R., an established patient, sees Dr. S. She had an IUD inserted 5 years ago but is now experiencing bleeding and cramping. Dr. S. does an expanded problem-focused examination and takes additional history. They discuss removal of the IUD and other possible contraceptive methods. After a brief discussion, Ms. R. selects the implant. Dr. S. removes the IUD without problems and inserts an implant.

How should Dr. S. code for this visit?

Dr. S. reports codes 11981 (implant insertion) and 58301-51 for the IUD removal. Code 11981 is reported first because it has the higher RVU, and the modifier 51 (multiple procedures) is added to the lesser procedure. Dr. S. also reports the diagnosis codes Z30.431 (routine checking of IUD), Z30.432 (removal of IUD), and Z30.017 (initial prescription of implantable subdermal contraceptive [includes insertion]) and the J7307 (etonogestrel [contraceptive] implant system, including implant and supplies) supply code. Dr. S. might also report an E/M services code for the examination, history, and medical decision making if his documentation is sufficient. If an E/M services code is reported, a modifier 25 (significant, separately identifiable E/M service) is added. This code is linked to diagnoses for pain, cramping, and complications of an IUD, if appropriate.

Scenario 4

Missing Strings

Ms. T. sees Dr. U. because she cannot feel the strings from an IUD inserted last year. Dr. U. completes an examination and locates the strings.

How should Dr. U. code for this visit?

Coding will depend on the extent of the work involved and documented. If Dr. U. performs an examination and finds the missing strings fairly easily, she will report a low level E/M services code linked to diagnosis Z30.431 (routine checking of IUD). If, on the other hand, a more extensive examination is needed, she reports a higher level of E/M service linked to diagnosis T83.32XA (displacement of IUD, initial encounter). If the IUD had been removed during this visit, she would report 58301-22 (removal) instead of an E/M service. The modifier 22 indicates that this was more difficult than a simple removal of the IUD. A diagnosis T83.32XA (displacement of IUD, initial encounter) would help support the use of the modifier 22, but documentation must also indicate the additional work performed and risk to the patient.

Scenario 5

Difficult Insertion

Ms. V. sees Dr. W., and requests insertion of a copper IUD. Ms. V. weighs 220 lbs and has a BMI of 40.2. Dr. W. inserts an IUD with some difficulty due to Ms. V.’s body habitus.

How should Dr. W. code for this visit?

Dr. W. reports 58300-22 (insertion) and J7300 (Intrauterine copper contraceptive [Paragard®] [10 year duration]) for the IUD supply. No E/M services code is reported. Dr. W. documents the additional work, complexity, and risk to the patient involved in this case to support use of the modifier 22. The diagnosis codes are Z30.430 (insertion of IUD), Z68.41 (body mass index [40.0-44.9] adult), and E66.01 (morbid obesity due to excess calories).

Scenario 6

Hysteroscopic Removal

Ms. X. had an IUD inserted two years ago and is having severe cramping and menorrhagia. Dr. Y. does an examination, takes a history, and decides that the IUD is impacted. Dr. Y. completes a hysteroscopic removal of the IUD.

How should Dr. Y. code for the visit?

Dr. Y. reports an E/M services code with a 25 modifier for the examination, and code 58562 (hysteroscopy, surgical; with removal of impacted foreign body). The diagnosis code is T83.39XA (mechanical complication of IUD, initial encounter). The modifier 25 is added to the E/M code to indicate that a significant, separately identifiable E/M service was provided on the same day as a procedure. The E/M service and the procedure should be clearly documented in separate sections of the record. 

Scenario 7

Discontinued Insertion

Ms. Z. sees Dr. A, and requests insertion of an IUD. She is a new patient. After a brief discussion of the benefits and risks, Dr. A. attempts to insert a copper IUD. Dr. A. tries several times to insert the device, but Ms. Z.’s cervical os is stenotic, and Ms. Z. is experiencing a great deal of pain. Dr. A. discontinues the procedure. Dr. A. discusses other possible methods of contraception with Ms. Z. and she decides to try oral contraceptives. This conversation lasts 20 minutes. The total time of the office visit was 35 minutes.

How should Dr. A. code for the discontinued procedure and the visit?

Dr. A. reports 58300-53 (insertion) and J7300 (intrauterine copper contraceptive [Paragard®] [10 year duration]) for the IUD supply. The modifier 53 indicates that the procedure was attempted but unsuccessful. Dr. A. can also report E/M code 99203-25 (new patient office visit) for the counseling, since more than half of the E/M services time with the patient was spent in counseling. The medical record must include the subjects discussed, the time spent counseling, and the total time for the visit.

Scenario 8

Immediate Postpartum

Insertion Ms. B. is a 33 year old G3P2 patient of Dr. C. She delivered both previous pregnancies by cesarean. During antepartum care, Ms. B. expressed desire for an IUD postpartum, and the benefits and risks of an IUD were discussed. The decision was made to have the IUD inserted immediately after delivery. At 40 weeks 1 day following an uncomplicated antepartum course, Ms. B. presents to the hospital. Ms. B. delivers her third child by cesarean followed immediately by a copper IUD insertion. She is scheduled for her routine six week postpartum visit.

How should Dr. C code for the global obstetric care and immediate postpartum IUD insertion?

The table below summarizes the codes reported for this scenario. For obstetric services, Dr. C. reports global CPT code 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care) with outcome of delivery diagnosis codes O34.21- (maternal care for scar from previous cesarean delivery), Z37.0 (single live birth), and Z3A.40 (40 weeks gestation of pregnancy). For the IUD insertion, Dr. C reports 58300-51 (insertion). HCPCS code J7300 (intrauterine copper contraceptive [Paragard®] [10 year duration]) is reported for the IUD supply. The modifier 51 (multiple procedures) is added to CPT code 58300 to indicate the additional procedure (IUD insertion) performed at the same session as the primary procedure (delivery). The diagnosis code is Z30.430 (insertion of intrauterine contraceptive device). 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.

 

Diagnosis Code	Procedures/Supplies	Modifier
O34.21- Maternal care for scar from previous cesarean delivery Z37.0 Single live birth Z3A.40 40 weeks gestation of pregnancy	Z30.430 Encounter for insertion of intrauterine contraceptive device
59510 Routine obstetric care including antepartum, cesarean delivery, and postpartum care	58300 Insertion of IUD J7300 Intrauterine copper contraceptive (Paragard®) (10 year duration)	51