Primary Care Coding Alert

"Question: One of our patients came in complaining of cramping and bleeding in between her periods. She has used an IUD for a little more than a year. Our physician conducted a pelvic exam and determined that the IUD should be removed, which he did. How would this be coded?

Colette Litchfield
Washington, D.C.

Answer: You would report two procedure codes in this situation, each with its own diagnosis codes.

Report the office visit to determine the cause of the cramping and bleeding by assigning an E/M code (e.g., 99213 or 99214 for an established patient, or 99203 for a new patient). The appropriate diagnosis codes are 626.6 (metrorrhagia) and V25.42 (surveillance of previously prescribed contraceptive methods; intrauterine contraceptive device).

You would then assign 58301 (removal of intrauterine device [IUD]) and again list V25.42 with 626.6 because that is the reason for removal of the IUD. The ICD-9 description for the CPT code includes checking, reinserting or removing an IUD.

You may also need to add modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code to distinguish it from the code describing the removal of the IUD."