Wiki IUD removal considered surgical procedure??

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erthsvr

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Hi all!

We have a claim that was denied by a commercial insurance carrier for an IUD removal. This was the patient's first visit to this OB/GYN as she is a student at a local college and had an IUD removal r/t lower abdominal pain. The office billed a 58301 (IUD Removal) and a 99204-25 (Office/Outpatient Visit, New). The insurance carrier denied the 99204 stating that it is included in surgical procedure. There are no edits in CCI Edit v.15.1 and there are notes indicating this in CPT Professional 2010. When we called the insurance company, they stated that "it is a surgery b/c anytime a you go inside the body it is considered surgery." As a nurse and medical professional, I don't agree with that statement or we would all be charged a surgical procedure for Foley insertion, speculum insertion for pap smears, etc.

Has anyone had this occur before? And if the IUD removal is indeed considered a surgical procedure with a global period on it, can you please lead me in the right direction for some documentation?

Thanks :)

Heather MacPherson, LPN, CPC, CPC-H
 
"0" global days

This is NOT my area of expertise but ...

58301 has "0" global days assigned, so Mod 25 is the correct modifier.

However, is it possible that this insurance carrier wants a -57 modifier? I know that the coding book would say this is wrong since the "surgery" was not a major procedure (90 days global), but some insurance carriers do not read the CPT (or at least they don't seem to).

OR ... could this be a carrier that does not want ANY modifier on a new patient visit. There have been posts about this issue, the idea being that by definition a "new patient" visit is significantly separate from any procedure and therefore exempt from needing the modifier.

Just "typing" out loud. Hope that helps.

F Tessa Bartels
 
IUD removal

CPT code 58301 has a "0" day global period. Did you link dx v25.42 Encounter for contraceptive management; surveillance of previously prescribed contraceptive methods; intrauterine contraceptive device, Checking, reinsertion, or removal of intrauterine device to 58301 & Abd pain 789.00 to the office visit?
 
You need to link your dx as 99204-25 and 789.03; 58301 and V25.42. Write an appeal as opposed to calling the carrier. State that this is a new patient to the practice and that the need to asses the patient/situation before the final decision. There was a similar situation occur with an orthopedic physician. The physician coded a new visit, 99204 and then fracture care. The physician won the argument for the need to assess before reducing a fracture and got paid for both procedures. The local Blue Cross plan then made a ruling and all orthopedics in that state got paid for an E/M and fracture care on the same day as long as they used modifier -25 on the E/M.

Good Luck!
 
Since it also seemed to be removed due to a complication of, try using 996.65 as well. I would code the 99204-25 with the abdominal pain and 789.03, 996.65 for the removal and appeal with the information that this was a "New" patient, therefore the E & M is completely valid and the decision to remove the IUD was made at the time of service. I think a lot of carriers systems automatically deny an office visit when billed with a procedure and require an appeal and notes to get it paid.
 
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