IUD Coding: Specific Clinical Scenarios Coding for the ...

1 LARC Quick Coding Guide 2012 UPDATE. Difficult Insertions If the procedure is performed successfully at a later date, the payer The 22 modifier can be reported if the work required to insert will be more likely to recognize that the rst claim (reported with a IUD Coding : Speci c Clinical Scenarios an IUD is substantially greater than usual. The 22 modifier can also be reported in the case of an unsuccessful insertion modi er 53) and the second one are not duplicates. followed by a successful insertion during the same surgical IUD Reassessment E/M Service and IUD Insertion The following table illustrates Coding when an IUD insertion and an of ce visit occur at the same encounter. Under certain session. A modifier 22 is added to code 58300 (Insertion of ICD-9-CM code (Surveillance of previously prescribed contra- Coding for the Contraceptive Implant and IUDs IUD) ( , 58300-22). ceptive method, intrauterine device) is assigned for a follow-up visit circumstances and when supported by documentation, it may be appropriate to report a CPT procedure code, an E/M code, in the of ce to check the proper placement of the IUD.

2 C O R R E C T C O D I N G can result in more appropriate compensation for services. To help practices receive Documentation must support the substantial additional work and a HCPCS supply code for the one visit. Diagnostic codes are reported based on services provided, such as outpatient appropriate payment for providing the contraceptive implant and intrauterine devices (IUDs), the American and the reason for the additional work, such as: increased or preventive services, as appropriate. Use of Ultrasound College of Obstetricians and Gynecologists' Long-Acting Reversible Contraception (LARC) Program, in intensity or time, increased technical difficulty of performing The performance of an ultrasound to check IUD placement is not collaboration with the American Congress of Obstetricians and Gynecologists' Coding Department, has the procedure, severity of patient's condition, increased physical bundled into the IUD insertion (code 58300), and it is not common prepared this updated quick reference guide to Coding for LARC methods.

3 The information included in this and mental effort required. The physician should specifically Coding for IUD Insertion and E/M Service practice to use ultrasound to con rm placement. Therefore, this guide is current as of March 1, 2012. For more information about the LARC Program and Coding for LARC. q document the total time of the procedure and how it compares should not be routinely billed. However, ultrasonography may be with the typical duration of the procedure. methods, go to CPT PROCEDURES AND SERVICES MODIFIER DIAGNOSIS(ES). used to con rm the location of the IUD when the physician incurs a dif cult IUD placement ( , severe pain, uterine perforation, etc.). Discontinued IUD Insertion 58300 Insertion of IUD Insertion of intrauterine contraceptive device If ultrasound is used, one of the following codes is added: Basic Contraceptive Implant Coding On occasion, a clinician may elect to discontinue the IUD. insertion due to extenuating circumstances or a threat to the Code 76857 Ultrasound, pelvic [nonobstetric], real time with The contraceptive implant is a single-rod etonogestrel-releasing contraceptive device inserted under the skin of the 992XX E/M based either on the key components or 25 General counseling and advice, initiation of other patient's well-being.

4 A modi er 53 (Discontinued Procedure) is image documentation; limited or follow-up, or upper arm. The insertion and/or removal of the implant are reported using one of the following CPT codes: time spent counseling contraceptive measures added to code 58300 (Insertion of IUD) ( , 58300-53). This Code 76830 Ultrasound, transvaginal 11981 Insertion, non-biodegradable drug delivery implant modi er is used when a procedure is started but discontinued 11982 Removal, non-biodegradable drug delivery implant Occasionally, ultrasound is needed to guide IUD insertion. If ultra- HCPCS SUPPLY CODES and no other procedure is performed during the visit. 11983 Removal with reinsertion, non-biodegradable drug delivery implant sound is used, add code 76998 (Ultrasonic guidance, intraoperative). Modi er 53 provides a way to receive partial payment for work The diagnostic Coding will vary, but usually will be selected from the V25 (Encounter for contraceptive management). J7300 Intrauterine copper contraceptive Insertion of intrauterine contraceptive device performed before the procedure is discontinued.

5 It is not neces- Same Day IUD Removal and Reinsertion series in ICD-9-CM. These codes are: sary to reduce the fee. The payer will determine the fee for the The following chart shows Coding when an IUD is removed and a new OR Encounter for contraceptive management, insertion of implantable subdermal contraceptive service. The payer may require documentation showing how one inserted during an of ce visit. When appropriate and supported Surveillance of previously prescribed contraceptive method; implantable subdermal contraceptive. much work was actually performed. This modi er is also useful by documentation, two CPT procedure codes, an E/M code, and J7302 Levonorgestrel-releasing intrauterine Insertion of intrauterine contraceptive device This code is reported for checking, reinsertion, or removal of the implant. because it tells the payer that the procedure was unsuccessful. a HCPCS supply code are reported for the one visit. A modifier 51. contraceptive system, 52mg (Multiple Procedures) is added to code 58300.

6 The CPT procedure codes do not include the cost of the supply. Report the supply separately using a HCPCS. (Healthcare Procedural Coding System) code: OR Coding for Same Day Removal and Reinsertion of IUD with an E/M Service J7307 Etonogestrel [contraceptive] implant system, including implant and supplies q CPT PROCEDURES AND SERVICES MODIFIER DIAGNOSIS(ES) CPT PROCEDURES AND SERVICES MODIFIER DIAGNOSIS(ES). Basic IUD Coding 58300 Insertion of IUD Insertion of intrauterine contraceptive device 58301 Removal of IUD Removal and reinsertion of intrauterine Intrauterine devices include the copper IUD and the hormonal IUD. The insertion and/or removal of IUDs are reported contraceptive device using one of the following CPT codes: 58300 Insertion of IUD. 9939X or 9938X Preventive E/M service based on 25 Routine gynecological examination age and whether a new or established patient 58300 Insertion of IUD 51 58301 Removal of IUD. General counseling and advice, initiation of other contraceptive measures Most IUD services will be linked to a diagnosis code from the V25 series (Encounter for contraceptive management): 992XX E/M based either on the key components 25 Removal and reinsertion of intrauterine Insertion of intrauterine contraceptive device or time spent counseling contraceptive device HCPCS SUPPLY CODES Removal of intrauterine contraceptive device HCPCS SUPPLY CODES Removal and reinsertion of intrauterine contraceptive device J7300 Intrauterine copper contraceptive Insertion of intrauterine contraceptive device Surveillance of previously prescribed contraceptive method, intrauterine device J7300 Intrauterine copper contraceptive Insertion of intrauterine contraceptive device OR The CPT procedure codes do not include the cost of the supply.

7 Report the supply separately using a HCPCS code: OR J7300 Intrauterine copper contraceptive J7302 Levonorgestrel-releasing intrauterine Insertion of intrauterine contraceptive device or J7302 Levonorgestrel-releasing intrauterine Insertion of intrauterine contraceptive device contraceptive system, 52mg J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg contraceptive system, 52mg CPT copyright 2011 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability CPT only 2011 American Medical Association. All Rights Reserved. CPT only 2011 American Medical Association.

8 All Rights Reserved. for data contained or not contained herein. Reporting E/M Services Code Only Contraceptive Implant Coding : Speci c Clinical Scenarios Contraceptive If a patient comes in to discuss contraception options but no procedure is provided at that visit: E/M Service and Implant Insertion Implant Reassessment Services with The following table illustrates Coding when an implant insertion and an of ce visit occur at the same encounter. Under ICD-9-CM code (Surveillance of previously prescribed contraceptive method; implantable subdermal contraceptive). Other Services If the discussion takes place during an annual preventive visit (99381 99387 or certain circumstances and when supported by documentation, it may be appropriate to report a CPT procedure code, is assigned for a follow-up visit in the of ce to check, reinsert, or remove the implant. If the patient has symptoms, report 99391 99397), it is included in the Preventive Medicine code. The discussion is not an E/M code, and a HCPCS supply code for the one visit.

9 Diagnostic codes are reported based on services provided, these as secondary diagnoses. For example, code (contusion, upper arm), or other physical symptoms such as Under some circumstances, reported separately. such as outpatient or preventive services, as appropriate. code (nausea). an Evaluation and Management If the discussion takes place during an E/M of ce or outpatient visit (99201 99215), (E/M) services code, a procedure Same Day Implant Removal and Reinsertion an E/M services code may be reported if an E/M service (including history, physical code, and a HCPCS code, may all The following chart shows Coding when an implant is removed and a new one inserted during an of ce visit. When examination, or medical decision making or time spent counseling) is documented. be reported. Coding for Implant Insertion and E/M Service Link the E/M code to ICD-9-CM diagnosis code (General family planning q appropriate and supported by documentation, a CPT procedure code, an E/M code, and a HCPCS supply code are counseling and advice).

10 Reported for the one visit. CPT PROCEDURES AND SERVICES MODIFIER DIAGNOSIS(ES). ACOG Fellows and their staff can submit specific Coding questions 11981 Insertion, non-biodegradable drug Encounter for contraceptive management, to the ACOG Department of delivery implant insertion of implantable subdermal contraceptive E/M Services Code and Procedure Code Coding and Nomenclature at Coding for Same Day Removal and Reinsertion of Implant with an E/M Service If discussion of contraceptive options takes place during the same encounter q or by fax to 992XX E/M based either on the key components 25 General counseling and advice, initiation of other as a procedure, such as insertion of a contraceptive implant or IUD, it may 202-484-7480. Questions are or time spent counseling contraceptive measures CPT PROCEDURES AND SERVICES MODIFIER DIAGNOSIS(ES). or may not be appropriate to report both an E/M services code and the answered in the order received, procedure code: HCPCS SUPPLY CODES.