Wiki IUD Insertion discontinued at patient request

[chandise.pratt@lpnt.net]

This is a new and rare circumstance for me and I am seeking feedback on how to best code this encounter.

16 yo, female patient presents to the office for IUD insertion (mother is present). Consents are signed, negative UPT obtained. With patient in dorsal lithotomy position, speculum is placed in the vagina and the cervix and vagina are prepped with Betadine. At this point, the patient would not allow the provider to move forward with the IUD insertion due to "fear of discomfort". The Kyleena device had already been removed from the packaging, so it is unable to be restocked. Patient stated that she "felt weird" and wanted to confirm that she was not pregnant. At that point, an US was done and the patient was shown the negative UPT, but she still chose to not move forward with the insertion and declined an alternate contraception.

I felt that the coding should be as follows:

* I will also be billing for the UPT and the Kyleena device*

- 58300 w/ 53 modifier with my argument being that even though the patient did not express present physical discomfort, she had mental discomfort with moving forward with the procedure.

- 76856; there is no medical necessity for performing the US, so I was going to use ICD-10 codes Z71.1 and Z71.2, since it was done at the patient's request for confirmation of the negative UPT.

Please let me know if any of you have had a similar situation and if you think the codes I have used are as accurate as possible.

Thank you!

 

[csperoni]

In this situation, I would not bill for IUD insertion (even with -53) as they did not start the IUD insertion. They basically did a pelvic exam. If clinician had put the Kyleena in vagina and then procedure was stopped, I would agree with 58300-53.
The sonogram is tricky. If you are stating there was no medical necessity, then it shouldn't be billed at all. In my opinion, there kind of was medical necessity - the patient was concerned which prompted the testing. I would want to confirm it was a COMPLETE pelvic sono and not 76857 limited. If you could consider the ultrasound a pregnancy "test" then maybe Z32.01?? Or the encounter for IUD is actually why the patient was there, and could still be appropriate even though IUD not completed.
Z53.09 procedure and treatment not carried out due to other contraindication is another possibility.
I would likely bill an E&M here (maybe based on time if documented) and possibly the sono.
If the practice supplied the Kyleena, you can reach out to your rep and may be able to get a replacement device.