Wiki IUD Removal documentation requirements

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I work in a primary care office, and one of our patients came in to have her IUD removed. The provider wrote a brief E&M note for the visit, but the only documentation on the actual procedure is "Paraguard IUD removed without difficulty." I'm skeptical as to whether this is enough documentation to bill a 58301, and wondering if I should just bill the low-level E&M that the full note supports. I definitely can't bill both, but I'm not sure which direction I should go in. Thoughts on whether I can bill it as a 58301?
Thanks!
 
"One of our patients came in to have her IUD removed."

I think you need to look at WHY the patient came into the office. If it was specifically to have the IUD removed as you said, then you would just code for the removal and not the E/M.
 
I do understand that the procedure code is more appropriate for the situation. I'm wondering about the documentation - is it sufficient to support the 58301 if the record is ever reviewed? I just don't know enough about documentation requirements for this!
 
Yeah it's not great but it is enough. They really should be describing the procedure in a bit more detail.
 
maparso96 said:
Yeah it's not great but it is enough. They really should be describing the procedure in a bit more detail.
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are you guys still code 58301 when provider unable to remove the paragard. the documentation was complete but unsuccessful to removed the IUD. I'm thinking I should have still bill 58301 although the procedure is unsuccessfully but I wasn't confident and also can't find any guidelines. if anyone can help me your thought please!!! Thanks
 
You could use 58301 and add modifier 52 for reduced services, if the iud was not removed. I'm not sure if you will get paid for this or not though.
 
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