EM Coding Alert

Question: My ob-gyn either inserts or removes an IUD at the same time as an E/M or preventive visit. Can I report both?

Illinois Subscriber

Answer: Yes, provided your ob-gyn’s documentation supports using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Make sure your physician has his notes in order, because chances are you’ll have to appeal.

If the visit qualifies as a preventive service (such as when the patient undergoes an annual visit at the same encounter as an IUD removal), then you should add modifier 25 to a preventive services code (99381-99397). Theoretically, you should receive reimbursement for both the removal and the preventive service.

The same holds true for a new- or established-patient office visit code (99201-99215, Office or other outpatient visit ...). Suppose the patient presents to your office with complaints about pain. Because the ob-gyn does not know what is causing the pain, he does a full examination and determines the IUD is the cause. He removes it. Provided he documents this, you should be able to report 58301 and the office visit (99201- 99215) with modifier 25.

For instance, back in 2016, Humana published the following: “Insertion and removal of an intrauterine device (IUD) is reimbursable with a new or established family planning visit or an evaluation and management visit. However, all components of an evaluation and management visit must be met and documented, in addition to the IUD service, before the IUD service can be reimbursed.”

Watch out: The “theoretical” part comes into play, because some payers won’t pay for removals and prefer that you submit the E/M service only.