I work for an OB/Gyn and I have a question regarding follow-up visits after IUD insertion. Scenario: patient returns to practice approximately a month after having IUD inserted for a routine follow-up. If there are no problems reported with the visit, but the provider is checking the device via bimanual exam, would this be considered a 99213 or just a 99212? Thanks in advance for any advice/help with this!
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Wiki IUD Follow-Up Visit
- Thread starter chandise.pratt@lpnt.net
- Start date
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- iud check obgyn coding
For a healthy patient with IUD followup inserted for birth control only, no other problems or issues addressed, I don't see how you would get to 99213.
Let's break it down. MDM for 99213 requires 2 of 3 meet or exceed that level in problems, data, and risk
Problem: low requires 2 or more self-limited or minor problems, 1 stable chronic illness, or 1 acute uncomplicated illness or injury. Does not meet 99213 for problem.
Data: limited requires either order/review 2 tests or independent historian. Does not meet 99213 for data.
Risk: requires low risk of morbidity from additional diagnostic testing or treatment. You could possibly (if LNG IUD) consider that the provider is making the decision to continue the prescription drug released by the IUD. The documentation would need to reflect that. IF the documentation did reflect that, you would have moderate risk.
There is never an "always this level", and coding is based on the individual patient and documentation. That being said, absent an additional problem, or data, for a healthy patient, this will generally be 99212.
In my practice for example, we don't insert IUDs for birth control, but rather as a possible treatment option vs surgery for patients with endometrial cancer. In that case, they are evaluating and treating the cancer, and would often result in a higher level.
Let's break it down. MDM for 99213 requires 2 of 3 meet or exceed that level in problems, data, and risk
Problem: low requires 2 or more self-limited or minor problems, 1 stable chronic illness, or 1 acute uncomplicated illness or injury. Does not meet 99213 for problem.
Data: limited requires either order/review 2 tests or independent historian. Does not meet 99213 for data.
Risk: requires low risk of morbidity from additional diagnostic testing or treatment. You could possibly (if LNG IUD) consider that the provider is making the decision to continue the prescription drug released by the IUD. The documentation would need to reflect that. IF the documentation did reflect that, you would have moderate risk.
There is never an "always this level", and coding is based on the individual patient and documentation. That being said, absent an additional problem, or data, for a healthy patient, this will generally be 99212.
In my practice for example, we don't insert IUDs for birth control, but rather as a possible treatment option vs surgery for patients with endometrial cancer. In that case, they are evaluating and treating the cancer, and would often result in a higher level.
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Thank you for your feedback. We had a meeting with our providers and they were thinking that it would be a level 3 visit and I was explaining that the level of MDM just was not there to justify it and that it should be a level 2 visit, unless the patient presented with additional problems resulting in additional testing. I also added that if they documented time spent with the patient and it was 20-29 minutes, then we could bill a 99213, but they rarely spend that amount of time with an IUD follow-up/string check.
I did speak to the providers about documenting time and that if they spent 20-29 minutes on the patient's care, then that would justify me billing a level 3 visit. Thank you for your feedback.