Ob-Gyn Coding Alert

Question: A patient has an intrauterine device (IUD) place in the morning. She returns to the office late in the same day in pain and wants the IUD removed. The ob-gyn removes it. Is this considered two office visits? Do you still bill for the IUD? Any modifier needed? I am stumped.

South Carolina Subscriber

Answer: Unless your ob-gyn documented a separate and distinct evaluation and management (E/M) service, you should not bill an office visit at all.

You should certainly bill for inserting the IUD (58300) and the removal (58301). You provided the services and should be paid for the work of both. As 58300 does not have any global days, these two codes should not be subjected to National Correct Coding Initiative (NCCI) edits, and you should not need a modifier for the removal. Notice the “should not” in that sentence, as some carriers will create their own policies regarding these types of situations. Also, note that the code 58300 is not a Medicare-covered service. For this reason, no NCCI edits were created with this code.