Wiki Complications after IUD insertion

[jonique.dietzen]

Hello, I need some help.

The patient came in for a standard IUD replacement. She had the old IUD removed and a new one placed.
58301, 58300+51, J7298

But then an hour later the patient returns complaining of extreme cramping. The same provider then removes the new IUD and sends the patient to the ER to be evaluated for perforation.
58301

So now I have two questions.

1) Do I bill two occurrences of 58301 with modifier XE?
2) Do I bill for the device or return it to the manufacturer as defective?

Thanks,
Jonique Dietzen, CPC

 

[bonnyr]

Bonnyr, COBGC

You would bill the removal of the initial IUD, 58301, then 58300 for insertion of the new IUD, appended with modifier 51 for multiple procedures, then 58301 with modifier 76, for repeat procedure or service by the same physician and modifier XE for the second removal. You will probable have to send chart notes detailing why the second procedure was performed. You can also expect a fairly large reduction in payment on the second removal procedure.

I would bill the insurance for the device unless further evaluation at the hospital show it was defective. If it's defective, return to your manufacturer. It the uterus was perforated, this may not be due to the device, but by human error.