Primary Care Coding Alert

And find out how to code an unsuccessful procedure.

While many women prefer to see a gynecologist to discuss and manage their cycles, many choose instead to see their primary care practitioner (PCP). This means that many family medicine practices perform intrauterine device (IUD) insertion and removal procedures. As primary care coders, however, you may not have the experience needed to feel confident handling these types of claims.

Coding IUD procedures can be tricky, mostly because not all payers have the same submission criteria. Here, we’ll explain how to navigate payer preferences and submit clean IUD claims every time.

Procedure refresh: An IUD is a quarter-size device that’s shaped like a “T” and fits inside the uterus to prevent pregnancy. A nurse or doctor uses a speculum to open the vagina and uses an applicator to insert the IUD through the opening of the cervix. This usually takes less than 5 minutes.

Navigate the Insertion and Removal Codes

ICD-10: Look toward the Z30 diagnosis codes for contraceptive management. For your primary diagnosis, choose from one of the following codes:

• Z30.430 (Encounter for insertion of intrauterine contraceptive device)
• Z30.431 (Encounter for routine checking of intrauterine contraceptive device)
• Z30.432 (Encounter for removal of intrauterine contraceptive device)
• Z30.433 (Encounter for removal and reinsertion of intrauterine contraceptive device)

CPT^®: There are only two CPT^® codes you’ll have to think about:

• 58300 (Insertion of intrauterine device (IUD))
• 58301 (Removal of intrauterine device (IUD))

Insertion: When the physician inserts an IUD, you should report 58300. Link this code with Z30.430, according to Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Removals: Pair 58301 with Z30.432 for routine removals, Witt instructs. However, if the provider is removing the IUD because of a complication, you may need to also submit a 

complication code. For example, you may need to consider one of the following, based on the provider’s documentation:

• T83.31XA (Breakdown [mechanical] of intrauterine contraceptive device, initial encounter)
• T83.32XA (Displacement of intrauterine contraceptive device, initial encounter)
• T83.39XA (Other mechanical complication of intrauterine contraceptive device, initial encounter)

Recognize the Risk in Reporting Same-Day Insertion and Removal

Many payers continue to deny claims where you report codes for both the insertion and removal on the same day, despite no National Correct Coding Initiative (NCCI) bundle preventing you from reporting this code combination.

Beware combination code Z30.433: Because many payers aren’t willing to pay for both procedures on the same day, Z30.433 might not be your go-to for those encounters. “I’m a bit skeptical that the combined code will be a valid code for the payer who only allows for the insertion — rather than removal and insertion,” says Jan Rasmussen, PCS, CPC, ACSOB, ACS-GI, owner and consultant of Professional Coding Solutions in Holcombe, Wisconsin.

Coding alert: It’s important to pay attention to the payers that reimburse for only the removal when billed for both procedures. “Make a note of the basis for denial of the insertion,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. If it’s denied as non-covered and designated as patient responsibility, you will be able to collect from the patient for it. Knowing that ahead of time allows you to alert the patient. “If insertion is denied as ‘bundled’ with the removal or otherwise not the patient’s responsibility, then you are effectively stuck with payment for the removal only when both are done on the same date,” Moore continues.

Know How to Report IUD Procedures with an E/M

Your primary care physician either inserts or removes an IUD at the same time as an evaluation and management (E/M) or preventive visit. Can you report both?

In short, yes. However, this likely calls for 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) to be appended to the E/M as well as adequate provider documentation supporting it.

For example, suppose the patient presents to your office with complaints about pain. Because the PCP does not know what is causing the pain, they do a full examination and determine the IUD is the cause. They remove it. Provided they document this, you should be able to report 58301 and the office visit for the new or established patient office visit code (99202-99215, Office or other outpatient visit ...) with modifier 25.

Watch out: It’s possible still that some payers will prefer you submit only the E/M service and won’t reimburse the IUD removal. Check with the payer to find out.

Select Modifier 53 or 52 for Failed Insertion

Sometimes, your provider’s attempt to insert the IUD is unsuccessful. This can happen for a variety of reasons, including (but not limited to) the patient having a tipped or anteflexed uterus, making insertion uncommonly difficult. Or, the insertion can simply be intolerably painful, which causes the patient to request the physician stop the procedure. Anytime a procedure is started but not completed, you need to decide whether to append modifier 53 (Discontinued procedure) or modifier 52 (Reduced services) to the procedure code.

Modifier 53: While the American College of Obstetricians and Gynecologists (ACOG) generally recommends modifier 53, remember the CPT^® definition of the modifier, which tells you that “… due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate the surgical or diagnostic procedure was started but discontinued.” The definition also indicates the physician must have additionally performed the surgical prep in the operating suite and/or anesthesia induction prior to discontinuing the procedure. Modifier 53 should not be used in the case of elective cancellation before the patient’s anesthesia induction and/or surgical preparation in the operating suite. Some patients may require a local anesthetic for IUD insertion, but not all.

This means that you should use modifier 53 only when extenuating circumstances or a threat to the patient’s well-being causes the physician to terminate insertion of the IUD. Apart from patient anatomy, other examples might include the patient fainting or developing an arrhythmia.

Modifier 52: If modifier 53 does not seem appropriate to the circumstances and the physician is unable to place the IUD or the procedure was otherwise started and electively cancelled (e.g., the patient changed her mind), append modifier 52. Unlike modifier 53, 52 implies the physician did at least some of the work involved with the procedure. In most cases, the amount of reduction is dependent on documentation that shows how much work was involved. If the uterus is anteflexed, or tipped, for example, the physician may not be able to insert the IUD. In those cases, more work and expertise would have been done than if the patient changed her mind in the procedure.

Remember: Check your payer policy to learn which modifier they prefer for the situation before you submit the claim.