Long-Acting Reversible Contraception (LARC) Quick Coding Guide

Specific Clinical Scenarios

Contraceptive Implant 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 Implant Insertion and E/M Service

OR 

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 E/M Service

IUD Coding

E/M Service and IUD Insertion

The following table illustrates coding when an IUD 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

OR

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 clinician 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