Revenue Cycle Insider

Question: I have a report from one of our obstetricians. The physician performed a vaginal delivery of a patient’s baby, and then the physician performed a transcervical intrauterine device (IUD) placement following delivery of the placenta. The documentation states the provider inserted a 13.5 mg Skyla^® IUD that the physician provided. How would I report the physician’s work?

New Hampshire Subscriber

Answer: Start by assigning the appropriate vaginal delivery code, such as 59409 (Vaginal delivery only (with or without episiotomy and/or forceps)). You’ll then use 58300 (Insertion of intrauterine device (IUD)) to report the IUD insertion following the vaginal delivery and delivery of the placenta, both of which are bundled into 59409.

Modifier needed: Review the patient’s individual payer preferences to check if it requires modifier 51 (Multiple procedures) appended to 58300.

Next, use Z30.430 (Encounter for insertion of intrauterine contraceptive device) and link it to 58300 to report the reason for the IUD insertion.

Finally, since the physician provided the IUD, you’ll need to include a HCPCS Level II code on the physician’s claim. Assign J7301 (Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg) for the 13.5 mg Skyla^® contraception device supply.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC