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Long-Acting Reversible Contraception (LARC) Quick Coding Guide

Coding for Contraceptive Impant and IUDs

Specific Clinical Scenarios

Contraceptive Implant Coding

E/M Service and Implant Insertion

The following information illustrates coding when an implant insertion and an office visit occur at the same encounter. Under certain circumstances and when supported by documentation, it may be appropriate to report a CPT procedure code, an E/M code, and a HCPCS supply code for the one visit. Diagnostic codes are reported based on services provided, such as outpatient or preventive services, as appropriate.

Coding for Implant Insertion and E/M Service
  • CPT Procedures and Service: 11981 Insertion, non-biodegradable drug delivery implant
  • Modifier: None
  • Diagnosis(es): Z30.017 Encounter for initial prescription of implantable subdermal contraceptive
  • CPT Procedures and Service: 992XX E/M based either on the key components or time spent counseling
  • Modifier: 25
  • Diagnosis(es): Z30.017 Encounter for initial prescription of implantable subdermal contraceptive
  • HCPCS Supply Codes: J7307 Etonogestrel (contraceptive) implant system, including implant and supplies
  • Modifier: None
  • Diagnosis(es): Z30.017 Encounter for initial prescription of implantable subdermal contraceptive 

Or

  • CPT Procedures and Service: 11981 Insertion, non-biodegradable drug delivery implant 
  • Modifier: None
  • Diagnosis(es): Z30.017 Encounter for initial prescription of implantable subdermal contraceptive
  • CPT Procedures and Service: 9939X or 9938X Preventive E/M service based on age and whether a new or established patient
  • Modifier: 25
  • Diagnosis(es): Z01.41- Routine gynecological examination (series) Z01.411 with abnormal findings Z01.419 without abnormal findings Z30.017 Encounter for initial prescription of implantable subdermal contraceptive
  • HCPCS Supply Codes: J7307 Etonogestrel (contraceptive) implant system, including implant and supplies
  • Modifier: None
  • Diagnosis(es): Z30.017 Encounter for initial prescription of implantable subdermal contraceptive

Implant Reassessment

ICD-10-CM code Z30.46 (encounter for surveillance of implantable subdermal contraceptive) is assigned for a follow-up visit in the office to check, reinsert, or remove the implant. If the patient has symptoms, report these as secondary diagnoses. For example, code S40.021 (contusion of right upper arm) or other physical symptoms such as code R11.0 (nausea).

Same Day Implant Removal and Reinsertion

The following chart shows coding when an implant is removed and a new one inserted during an office visit. When appropriate and supported by documentation, a CPT procedure code, an E/M code, and a HCPCS supply code are reported for the one visit.

CODING FOR same day removal and reINSERTION of implant with an AND E/M SERVICE
  • CPT Procedures and Services: 11983 Removal with reinsertion, non-biodegradable drug delivery implant 
  • Modifier: None
  • Diagnosis(es): Z30.46 Encounter for surveillance of implantable subdermal contraceptive 
  • CPT Procedures and Services: 992XX E/M based either on the key components or time spent counseling
  • Modifier: 25
  • Diagnosis(es): Z30.46 Encounter for surveillance of implantable subdermal contraceptive
  • HCPCS Supply Codes: J7307 Etonogestrel (contraceptive) implant system, including implant and supplies
  • Modifier: None
  • Diagnosis(es): Z30.46 Encounter for surveillance of implantable subdermal contraceptive

IUD Coding

E/M Service and Implant Insertion

The following table illustrates coding when an implant insertion and an office visit occur at the same encounter. Under certain circumstances and when supported by documentation, it may be appropriate to report a CPT procedure code, an E/M code, and a HCPCS supply code for the one visit. Diagnostic codes are reported based on services provided, such as outpatient or preventive services, as appropriate.

Coding for IUD Insertion and E/M Service
  • CPT Procedures and Services: 58300 Insertion of IUD
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • CPT Procedures and Services: 992XX E/M based either on the key components or time spent counseling
  • Modifier: 25
  • Diagnosis(es): Z30.014 Encounter for initial prescription of intrauterine contraceptive device
  • HCPCS Supply Codes: J7296 Levonorgestrel-releasing intrauterine contraceptive system (Kyleena®), 19.5 mg (5-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta®), 52 mg (4-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7298 Levonorgestrel-releasing intrauterine contraceptive system (Mirena®), 52 mg (5-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7300 Intrauterine copper contraceptive (Paragard®) (10-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla®), 13.5 mg (3-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device

Or

  • CPT Procedures and Services: 58300 Insertion of IUD
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device 
  • CPT Procedures and Services: 9939X or 9938X Preventive E/M service based on age and whether a new or established patient
  • Modifier: 25
  • Diagnosis(es): Z01.41- Routine gynecological examination (series) Z01.411 with abnormal findings Z01.419 without abnormal findings Z30.014 Encounter for initial prescription of intrauterine contraceptive device
  • HCPCS Supply Codes: J7296 Levonorgestrel-releasing intrauterine contraceptive system (Kyleena®), 19.5 mg (5-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta®), 52 mg (4-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7298 Levonorgestrel-releasing intrauterine contraceptive system (Mirena®), 52 mg (5-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7300 Intrauterine copper contraceptive (Paragard®) (10-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla®), 13.5 mg (3-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.430 Encounter for insertion of intrauterine contraceptive device

Use of Ultrasound

The performance of an ultrasound to check IUD placement is not bundled into the IUD insertion (code 58300), and it is not common practice to use ultrasound to confirm placement. Therefore, this should not be routinely billed. However, ultrasonography may be used to confirm the location of the IUD when the qualified clinicician incurs a difficult IUD placement (e.g., severe pain, uterine perforation, etc.). If ultrasound is used, one of the following codes is added:

  • Code 76857 Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up, or
  • Code 76830 Ultrasound, transvaginal

Occasionally, ultrasound is needed to guide IUD insertion. If ultrasound is used, add code 76998 (ultrasonic guidance, intraoperative).

IUD Reassessment

ICD-10-CM code Z30.431 (encounter for routine checking of intrauterine contraceptive device) is assigned for a follow-up visit in the office to check the proper placement of the IUD.

Difficult Insertions

The 22 modifier can be reported if the work required to insert an IUD is substantially greater than usual. The 22 modifier can also be reported in the case of an unsuccessful insertion followed by a successful insertion during the same surgical session. A modifier 22 is added to code 58300 (insertion of IUD) (i.e., 58300-22). Documentation must support the substantial additional work and the reason for the additional work, such as: increased intensity or time, increased technical difficulty of performing the procedure, severity of patient’s condition, increased physical and mental effort required. The qualified clinician should specifically document the total time of the procedure and how it compares with the typical duration of the procedure.

Discontinued IUD Insertion

On occasion, a clinician may elect to discontinue the IUD insertion due to extenuating circumstances or a threat to the patient’s well-being. A modifier 53 (discontinued procedure) is added to code 58300 (insertion of IUD) (i.e., 58300-53). This modifier is used when a procedure is started but discontinued and no other procedure is performed during the visit. Modifier 53 provides a way to receive partial payment for work performed before the procedure is discontinued. It is not necessary to reduce the fee. The payer will determine the fee for the service. The payer may require documentation showing how much work was actually performed. This modifier is also useful because it tells the payer that the procedure was unsuccessful. If the procedure is performed successfully at a later date, the payer will be more likely to recognize that the first claim (reported with a modifier 53) and the second one are not duplicates.

Same Day IUD Removal and Reinsertion

The following chart shows coding when an IUD is removed and a new one inserted during an office visit. When appropriate and supported by documentation, two CPT procedure codes, an E/M code, and a HCPCS supply code are reported for the one visit. A modifier 51 (multiple procedures) is added to code 58300.

Coding for Same Day Removal and Reinsertion of IUD with an E/M Service
  • CPT Procedures and Services: 58301 Removal of IUD
  • Modifier: None
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
  • CPT Procedures and Services: 58300 Insertion of IUD
  • Modifier: 51
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
  • CPT Procedures and Services: 992XX E/M based either on the key components or time spent counseling
  • Modifier: 25
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device

Or

  • HCPCS Supply Codes: J7296 Levonorgestrel-releasing intrauterine contraceptive system (Kyleena®), 19.5 mg (5-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta®), 52 mg (4-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7298 Levonorgestrel-releasing intrauterine contraceptive system (Mirena®), 52 mg (5-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7300 Intrauterine copper contraceptive (Paragard®) (10-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
  • HCPCS Supply Codes: J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla®), 13.5 mg (3-year duration)
  • Modifier: None
  • Diagnosis(es): Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device