How To Use CPT Code 58300

CPT 58300 describes the insertion of an intrauterine device (IUD) for contraceptive purposes. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58300?

CPT 58300 can be used to describe the procedure of inserting an intrauterine device (IUD) for contraception. This code is used when a healthcare provider places the IUD in the uterine cavity of a patient.

2. Official Description

The official description of CPT code 58300 is: ‘Insertion of intrauterine device (IUD)’. There are no additional notes or modifiers associated with this code.

3. Procedure

1. The healthcare provider positions the patient in the lithotomy position and performs a vaginal exam to assess the position of the uterus.
2. A speculum is inserted to hold the vaginal walls apart, and the cervix is cleaned with an antiseptic solution.
3. The provider uses a tenaculum to grasp the lip of the cervix and applies a numbing gel to the cervical canal.
4. An uterine sound is inserted into the uterus to measure the depth of the cavity.
5. If the uterus is greater than 6 cm, the provider prepares the IUD for insertion.
6. Using an inserting tube, the provider places the IUD into the uterus, allowing it to expand within the cavity.
7. The inserting tube is then withdrawn, and the provider trims the IUD string to 3 cm.
8. Bleeding areas, if any, are checked and addressed.
9. The speculum is removed, and the provider documents the depth of the uterine cavity and the length of the IUD string in the patient’s record.

4. Qualifying circumstances

CPT 58300 is performed for patients who require contraception and choose to have an IUD inserted. The procedure is typically done for women who are not pregnant and do not have any contraindications to IUD use. The patient must be under the care of a healthcare provider who is qualified to perform the insertion of an IUD.

5. When to use CPT code 58300

CPT code 58300 should be used when a healthcare provider performs the insertion of an IUD for contraceptive purposes. It is important to ensure that the patient meets the necessary criteria for IUD insertion and that the procedure is documented appropriately.

6. Documentation requirements

To support a claim for CPT 58300, the healthcare provider must document the following information:

• Patient’s consent for the IUD insertion
• Positioning of the patient and use of a speculum
• Cleaning of the cervix with an antiseptic solution
• Use of a tenaculum and application of numbing gel
• Insertion of the uterine sound to measure the depth of the uterine cavity
• Preparation and insertion of the IUD
• Trimming of the IUD string
• Assessment and management of any bleeding areas
• Removal of the speculum
• Documentation of the depth of the uterine cavity and length of the IUD string

7. Billing guidelines

When billing for CPT 58300, ensure that the procedure is performed by a qualified healthcare provider and that the documentation supports the medical necessity of the IUD insertion. It is important to follow the specific guidelines provided by the payer and to use the appropriate modifiers, if required.

8. Historical information

CPT 58300 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A healthcare provider inserts an IUD for a patient who desires long-term contraception.
2. A woman visits her gynecologist for an IUD insertion after discussing the various contraceptive options.
3. A healthcare provider performs an IUD insertion for a patient who has previously used other forms of contraception.
4. A young woman decides to have an IUD inserted as a reliable method of birth control.
5. A healthcare provider performs an IUD insertion for a patient who has completed her family planning.
6. A woman chooses an IUD as her preferred method of contraception and undergoes the insertion procedure.
7. A healthcare provider inserts an IUD for a patient who prefers a non-hormonal form of birth control.
8. A woman opts for an IUD insertion after discussing the potential benefits and risks with her healthcare provider.
9. A healthcare provider performs an IUD insertion for a patient who desires a long-acting reversible contraceptive method.
10. A woman decides to have an IUD inserted after considering the effectiveness and convenience of this form of contraception.