Wiki IUD removal

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aaseals32

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Location
Baker, LA
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Hi if a patient comes in for attempted iud removal would I code as follow:

z30.432
z53.8
z79.5
t83.32xa
z78.9

99213-25
58301-53


Assessment
1. Uses oral contraceptives as primary birth control method (Z78.9)
OCP refilled at time of visit.
Pt repots she ahs been on this OCP on the past with no apparent side effects.
Pt advised not to start OCP until IUD removed. Pt voice understanding.
2. Attempted IUD removal, unsuccessful (Z53.8,Z97.5)
Unable to remove IUD successfully due to inability to locate IUD strings.
Pt advised she will contact GUV provider who inserted IUD for further evaluation and
follow up. Pt declines order for US at time of visit stating she would rather F/U with GYN
for further management. Pt advised of the importance of follow up. Pt voice
understanding.


Plan
 Renew: Tri-Lo-Sprintec 0.18/0.215/0.25 MG-25 MCG Oral Tablet; TAKE 1 TABLET BY
MOUTH EVERY DAY
Follow up as needed or for further concerns.


Patient Plan/Instructions

Strict return precautions advised.
Pt to return for continued or worsening symptoms.
Pt voice understanding and agreement w/POC.

Chief Complaint

IUD removal

History of Present Illness
female who presents today for IUD removal with transition to OCP. Pt reports husband recently had vasectomy so IUD no longer needed and would like OCP for additional protection until husband cleared by urology for full sterilitly.
 
I find this link to be helpful when it comes to contraceptives. Also, it would depend on how the patient is scheduled for this encounter. You may only bill for the failed procedure. In order to bill an E/M with a procedure either the patient was scheduled as an office visit and the decision to perform the procedure was made then or the provider had a significant finding that now required an exam and addressing. Remember the descriptor for modifier 25 "....separately identifiable" . Hope this helps.

 
I'll assume the already provided link helped you with any diagnoses concerns. I think your Z79.5 is a typo and supposed to be Z79.3.

I will also re-iterate @vlcastro82 concern about billing an E&M along with a procedure that was already planned. I suppose you could make the case for "significant" by the MDM of prescribing OCP. If that's the case you are making, then I think 99213-25, 58301-53 may be overcoding the E&M. While you reach moderate risk for prescription management, I'm not sure you reach low for either problem or data. We can agree data is none so straightforward. That leaves problem - number and complexity of problems addressed. I would only count the problem of needing OCP renewal. I would consider that a straightforward problem. A more thorough discussion about contraceptive options/alternatives I could see counting as a low level problem, but that is not the case here. The other problem addressed - IUD removal I would not count since that work is already being compensated for in 58301-53.

I'll address another concern I have. I don't see documented that the physician even attempted to remove the IUD. Often if the strings are not visible, they will make other attempts to find the strings using a cytobrush or sometimes even an IUD hook. If that work was done, and strings still couldn't be located, then I would agree with 58301-53. This note seems to be - I took a look and didn't see the strings so referred her to gyn. If that was really the case, then I would not feel comfortable billing 58301-53 and instead bill an E&M only. Keeping in mind that now I would count the IUD removal problem and the issue of the lost strings. That would raise the problem beyond 99212 in my above paragraph, and no -25 required.
 
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