Ob-Gyn Coding Alert

The use of the contraceptive Norplant presents some interesting reimbursement challenges for the ob/gyn coder, says Jean Stoner, CPC, and Paula Ziemski, CPC, coding trainers for UPMC Health System, Pittsburgh, PA. Unlike other contraceptives, Norplant involves procedures for both insertion and removal, which may be combined with exams and office visits.

While some controversy continues around the use of Norplant, a recent publication released by the AMA states, Norplant is one of the most effective reversible methods of birth control available in the U.S. Part of Norplants appeal is it provides an effective means of contraception that is not dependent upon a patients vigilant compliance (as with contraceptive pills and other devices). Norplant is a hormonal implant that slowly releases levonorgestrel (a hormone similar to a womans own progesterone). It becomes effective within 24 hours of insertion and protects against pregnancy for five years. Only four women out of 100 who use Norplant for five years will become pregnant a rate less than one per year. Yet another appeal of Norplant is its reversible effects. Within a few hours after the implants are removed, Norplants effects disappear and conception is possible.

Unlike many contraceptives that do not involve the coder (because the physician simply writes a prescription or provides advice), Norplant involves procedures for both insertion and removal. The contraceptive comes in six Silastic capsules or packets about the size of match sticks that are placed under the skin in the patients arm. All six of the small rubbery implants are needed and constantly release small amounts of hormone into the patients body. The hormone keeps the ovaries from releasing eggs. It also thickens the cervical mucus, keeping sperm from joining with an egg or (some researchers suggest) by preventing a fertilized egg from attaching to the lining of the uterus.

The insertion of Norplant involves the administration of a local anesthetic and a single small incision site to place all six capsules under the skin. Insertion takes about 10 minutes. It is painless, except for the needle prick of the painkiller, although some women report feeling some discomfort for a while after insertion. Norplant can be inserted immediately after an abortion or following childbirth if the patient is not breast-feeding (six weeks after childbirth if patient is breast-feeding). Patients will be advised to make a follow-up visit within the first three months after insertion and once a year after that. Removal or replacements of the implants involve another small incision and takes a little longer than the original insertion.

Norplant Coding Scenarios

According to Stoner and Ziemski, the procedure codes used for Norplant are: 11975 (insertion, implantable contraceptive capsules), 11976 (removal, implantable contraceptive capsules), 11977 (removal and reinsertion, implantable contraceptive capsules). These CPT codes have a low value (2.86), so the medical and surgical supply codes A4260 (Levonorgestrel [contraceptive] implants system, including implants and supplies) or the general 99070 for supplies and materials are also reported. The procedure and supply codes would include the surgical tray and the local anesthetic.

The diagnosis codes that relate to Norplant implants and supervision are:

V25.5 - Insertion of implantable subdermal
contraceptive

V25.43 - Surveillance of previously prescribed implantable subdermal contraceptive

V45.52 - Postsurgical state: subdermal contraceptive implant

These procedure, supply and diagnosis codes will be used along with codes for other services provided at the same visit. The following illustrate some common coding scenarios.

If the primary purpose of the patients visit is for the implanting of Norplant, then coding will only include the appropriate procedure code (11975) the supply code (A4260) linked to the diagnosis code V25.5.

When the patient presents for a well-woman check and then has a contraceptive implanted, you will code for the appropriate preventive medicine code (99384-99387) appended with the 25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), the insertion code (11975), and the supply code. The same applies if the patient presents primarily for an E/M sick visit. You will use the appropriate E/M code appended with the 25 modifier and the insertion and supply codes.
For the patient who is seen for a normal postpartum exam that is part of her global ob charge, is not nursing, and requests Norplant, simply code the insertion and supply codes separate from the global codes.

Reimbursement Dependant on Provider

As with all contraceptive counseling, prescriptions and devices, reimbursement for Norplant and the associated procedures will depend on the patients health insurance coverage. For private payers, its always best to check on the patients coverage prior to insertion and advise the patient if they will be responsible for the cost. Medicaid covers the cost of Norplant in all states and in the District of Columbia. There is also a foundation set up by the manufacturer Wyeth-Ayerst to provide financial assistance for women who do not have insurance coverage (call 800-760-9030 for more information).