Wiki Initial Prescription of OCPs following a IUD removal

[ppaule]

Our provider sees a patient for an IUD removal. On the same day, provider started oral contraceptives. Is it appropriate to bill a separate E/M code for this reason? Appending modifier -25 to this E/M code.

Appreciate the reponse!

 

[csperoni]

It would depend on the documentation. For example, if at a prior visit the physician discussed removing the IUD and placing the patient on OCP at that time, probably not.
-25 means significant and separately identifiable E&M the same day as a procedure. I would take the documentation, and cross out everything that was part of the IUD removal, which gives you the separately identifiable. Is what is left significant? Or is it literally just one line of "Lo Loestrin Fe with 5 refills"?

 

[ppaule]

It would depend on the documentation. For example, if at a prior visit the physician discussed removing the IUD and placing the patient on OCP at that time, probably not.
-25 means significant and separately identifiable E&M the same day as a procedure. I would take the documentation, and cross out everything that was part of the IUD removal, which gives you the separately identifiable. Is what is left significant? Or is it literally just one line of "Lo Loestrin Fe with 5 refills"?

Thank you so much for responding, this is really helpful!