Ob-Gyn Coding Alert

Question: Can we bill for a well-woman exam and IUD insertion on the same day? If so, do we need a modifier? Can we also bill for an IUD removal on the same day?

California Subscriber

Answer: Yes, you can bill for both the preventive service (99381-99397) and the intrauterine device insertion (58300, Insertion of IUD) on the same day under CPT rules, but your payers- guidelines may be different. 

You would add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the preventive service code to show that it is separate from the IUD insertion. 

Watch out: Most payers will not allow you to bill for an IUD insertion and removal (58301, Removal of IUD) on the same day, but you can bill a removal with the preventive services code, again adding modifier 25 to the preventive service.