Ob-Gyn Coding Alert

Question: The patient came in two months post-intrauterine device (IUD) insertion asking if it was falling out. She felt strings at introitus. Upon exam, the ob-gyn could see the IUD in cervix via ultrasound and can easily remove it. He elected to bill an E/M (99213) instead of removal (58301) because a faulty device and/or placement caused the problem. Is his coding correct? Kentucky Subscriber Answer: You should bill the removal with 58301 (Removal of IUD) with a diagnosis of 996.32 (Mechanical complication due to intrauterine contraceptive device). Do not forget to include 76998 (Ultrasonic guidance, intraoperative). You can use either the same diagnosis (996.32) or a guidance ICD-9 code. Alternatively, you may simply report the code that represents IUD removal, V25.42 (Surveillance of previously prescribed contraceptive methods; intrauterine contraceptive device). Watch out: Reporting an E/M code for this service will not adequately capture the work performed.