Ob-Gyn Coding Alert

If you are constantly frustrated because your payer guidelines are all over the place when it comes to intrauterine devices (IUDs), then you're not alone. Some payers will reimburse IUD insertions but not removals, while others will include IUD removals in both office visits.

Traverse this veritable coding obstacle course by asking the following three questions. You'll learn more about a new coding stance from ACOG and pinpoint exactly what you should ask your payers to avoid both denials and missed ethical reimbursement opportunities.

Question 1: What CPT and ICD-9 codes should I report when an ob-gyn inserts or removes an IUD?

Answer 1: When your ob-gyn inserts an IUD, you should report 58300 (Insertion of intrauterine device [IUD]), says Christine Smith, office manager at Womencare OBGYN in Newton, N.J. Link this code with V25.1 (Insertion of intrauterine contraceptive device).

You should code removals with 58301 (Removal of intrauterine device [IUD]), Smith adds. If this is a routine removal, you should link this code with V25.42 (Surveillance of previously prescribed contraceptive methods; checking, reinsertion, or removal of intrauterine device).

If your ob-gyn is removing the IUD because of a complication, consult your documentation. You might use complication codes, says Veronica Antonelli, coding and compliance coordinator for Women's Care Florida in Tampa Bay. Some examples, she says, include:

• 996.32 (Mechanical complication due to intrauterine contraceptive device),

• 996.65 (Infection and inflammatory reaction due to internal prosthetic device,implant, and graft; due to other genitourinary device, implant, and graft), or

• 996.76 (Other complications; due to genitourinary device, implant, and graft).

Question 2: True/False -- You should consider IUD replacements as both insertion and removal.

Answer 2: Depends.

The American College of Obstetricians and Gynecologists (ACOG)'s advice is that you should consider this statement true. ACOG's May 2009 "Practice Management and Coding Update" (www.acog.org/departments/dept_notice.cfm?recno=6&bulletin=4828) released this information. Also, you'll find corroborating advice in CPT Assistant.

Red flag: You shouldn't overlook one tricky statement -- your payers' policies may differ.

Many payers continue to deny claims where you report codes for both the insertion (58300) and removal (58301) on the same day, despite no correct coding initiative (CCI) bundle preventing you from reporting this code combination. "Very few payers (if any) will pay for both services on the same day," says Patricia Larabee,CPC, CCP-P, coding specialist for InterMed in South Portland, Maine.

What's worse, payers often pay only the lesser valued code. Code 58300 has 2.07 relative value units (RVUs) while 58301 has 2.54. That means, your practice is out 0.47 RVUs or approximately $17, which can add up. Tactic: You should limit your reimbursement losses by billing 58301, because this code pays more than the other.

Be wary of other bundling issues associated with thesecodes. Success story: "When my ob-gyn did an IUD insertion and a biopsy, the payer denied the claim because 'the patient is in the same position for both procedures and both procedures were performed in the same anatomical area.' I had to go to a third-level appeal to win, but I did," says Cindy Foley, billing manager for three separate gynecology practices in Syracuse, N.Y. "I couldn't believe it! The same position and anatomical area? That's 90 percent of gynecology!"

Question 3: My ob-gyn either inserts or removes an IUD at the same time as an E/M or preventive visit. Can I report both?

Answer 3: Yes, provided your ob-gyn's documentation supports using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). "Make sure your physician has his notes in order, because chances are you'll have to appeal," Foley says.

If the visit qualifies as a preventive service (such as when the patient undergoes an annual visit at the same encounter as an IUD removal), then you should add modifier 25 to a preventive services code (99381-99397). heoretically, you should receive reimbursement for both the removal and the preventive service.

The same holds true for a new- or established-patient office visit code (99201-99215, Office or other outpatient visit ...). Suppose the patient presents to your office with complaints about pain. Because the ob-gyn does not know what is causing the pain, he does a full examination and determines the IUD is the cause. He removes it. Provided he documents this, you should be able to report 58301 and the office visit (99201-99215) with modifier 25.

Watch out: The "theoretical" part comes into play, because some payers won't pay for removals and prefer that you submit the E/M service only. For instance, Humana's position is that you should consider an IUD removal or insertion as incidental to an E/M or wellwoman exam, as a component of the overall service provided, Antonelli points out. Many payers have the same stance for an IUD check, which has no specific CPT ode. Check your payers' policies to see if this is the case.

Best bet: "My advice is to try to keep things separate," Foley says. "I realize the patient wants everything packed into one visit, but the doctor won't be fairly reimbursed for all the time and expertise without appealing to the highest levels. If she wants an IUD, set up a visit for that and another visit for the annual exam."