Ob-Gyn Coding Alert

Case Study:

Failed IUD Insertion? Here’s Why Choosing Between Discontinued, Reduced Services is Key

Don’t overlook your diagnosis coding selection.

When an ob-gyn attempts to place an intrauterine contraceptive device (IUD) and is unsuccessful, you’re often the one left with a quandary. What modifier should you include? The answer may depend on whose advice your payer follows.

Our experts break down this real-life IUD scenario.

First, Read This Procedure Note

Although IUD insertion and replacement situations may seem simple coding-wise, an attempted and unsuccessful insertion is not so easy. Read the following procedure note.

Procedure: Ms. S comes in today for IUD placement. After informed consent and using sterile technique, she was prepped and draped in the usual fashion. Sound was placed into the endometrial cavity without difficulty. Following this, I attempted to place an IUD. The IUD was very difficult to place. In fact, it became contaminated during placement.

A second attempt was made under ultrasound. We opened a second IUD and using ultrasound guidance attempted to place the IUD. It appeared that a false tract had been formed with the sound into the posterior uterus but had not perforated the uterus itself. I was unable to get the IUD to go around into the remarkably anteflexed uterus despite multiple attempts and manipulation of the cervix itself. It became very uncomfortable for Ms. S, and she asked that I stop. I stopped attempting to place the second IUD.

She has decided she wants to use Mircette birth control. A prescription was called in for this. Again, we attempted IUD placement and were unable to do it because of I think a false tract. I offered to place the second one at a later date, but she is not interested. We did use two IUDs today to attempt placement.

Examine Two Possible Solutions

The answer depends on whose advice your payer follows.

Option 1: According to the American College of Obstetricians and Gynecologists (ACOG), you should report 58300 (Insertion of intrauterine device [IUD]) and attach modifier 53 (Discontinued Procedure). The ob-gyn started but discontinued the service, and your practice should be able to receive partial payment for this work. Remember: Medicare does not pay for IUD insertions, so Medicare rules do not apply.

Opponents of this method point out that CPT®’s definition of modifier 53 states, “due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.” CPT®’s definition indicates that the physician must also have performed the surgical prep and anesthesia induction prior to discontinuing the procedure. Note that not every patient requires a local anesthetic for the IUD insertion.

Important: You should use modifier 53 when a patient experiences an unexpected response or life-threatening condition that causes the procedure to be terminated (such as the patient fainting or developing an arrhythmia). In other words, you shouldn’t append modifier 53 to report elective cancellation.

Payment reduction: Payers will reduce the allowable when this modifier is appended. For instance, Tufts Health Plan will reimburse only 20 percent of the allowable amount, while Harvard Pilgrim will allow 50 percent of the allowable.

Option 2: So what’s your alternative? Suppose your ob-gyn had applied a local anesthetic to the cervix prior to the insertion. If the ob-gyn could not place the IUD, you should consider this a failed procedure. Therefore, experts say you should use modifier 52 (Reduced services). You should add this to the procedure for the insertion (58300), experts say.

Payment reduction: Unlike modifier 53, modifier 52 implies the physician did at least some of the work involved in doing the procedure. In most cases, the amount of the reduction is dependent on documentation showing how much work was involved. In some cases, if the insertion attempt involved more significant work than normal placement, no reduction in payment will occur. For instance, in this case, the patient had a false track, but many insertions that involve cervical stenosis can be equally as difficult. Tufts indicates you would receive 70 percent or more of the allowable when you report a modifier 52.

Bottom line: Check with your payer to learn their preference before you submit your claim.

Strike Out Visit, Supply Codes

Here’s what you should not include on your claim.

The patient presented for the IUD placement. Because the visit didn’t go as planned and the ob-gyn discussed other birth control methods, you might be tempted to report an office visit (99202-99215, Office or other outpatient visit ...) — but here’s the catch: Your ob-gyn’s documentation must support using modifier 25 (Significant,separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Because the birth control discussion directly related to the IUD insertion, you don’t have a separate service to report the office code.

What about the supply codes? The ob-gyn did use two IUDs and contaminated both. You can capture the IUD supplies with:

  • J7300 (Intrauterine copper contraceptive)
  • J7296 (Levonorgestrel-releasing intrauterine contraceptive system, (kyleena), 19.5 mg)
  • J7297 (Levonorgestrel-releasing intrauterine contraceptive system (liletta), 52 mg)
  • J7298 (Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg)
  • J7301 (Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg)
  • S4989 (Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies)

But before you contemplate tacking on one of these codes onto your claim, you should know you cannot bill the patient or insurance when your practice still retains the IUDs. Contact the supplier and see if they will replace them, as your practice is now out the expense of these two IUDs, experts say.

Overlooking ICD-10 Could Cost You — Big

You need to make sure you choose the most appropriate diagnosis code for this case.

For your primary diagnosis, you can choose from one of the following diagnoses:

  • Z30.430 (Encounter for insertion of intrauterine contraceptive device)
  • Z30.431 (Encounter for routine checking of intrauterine contraceptive device)
  • Z30.432 (Encounter for removal of intrauterine contraceptive device)
  • Z30.433 (Encounter for removal and reinsertion of intrauterine contraceptive device)

In this case, you would report Z30.430.

Make sure you capture the “specificity with these IUD insertion, removal, and combined codes,” says Jan Rasmussen, PCS, CPC, ACSOB, ACS-GI, owner and consultant of Professional Coding Solutions in Holcombe, Wis.

Controversy: Be careful about using Z30.433, however. While you won’t find any National Correct Coding Initiative (NCCI) edit involving the insertion and removal an IUD on the same service date, many payers are not willing to pay for both services at the same encounter. “I’m a bit skeptical that the combined code will be a valid code for the payer who only allows for the insertion -- rather than removal and insertion, as ACOG maintains is possible,” Rasmussen says.

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