How To Use CPT Code 58301

CPT 58301 describes the procedure for the removal of an intrauterine device (IUD) from the uterine cavity. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 58301?

CPT 58301 can be used to describe the removal of an intrauterine device (IUD) from the uterine cavity. This code is used when a healthcare provider performs the procedure to remove the contraceptive device.

2. Official Description

The official description of CPT code 58301 is: ‘Removal of intrauterine device (IUD).’ There are no additional notes or modifiers associated with this code.

3. Procedure

1. The healthcare provider places the patient in the lithotomy position, which involves the patient lying on her back with knees bent and spread apart using stirrups.
2. A vaginal examination is performed to locate the IUD and check its position.
3. A speculum is inserted into the vagina to hold the vaginal walls apart.
4. The provider locates the IUD strings and grasps them with ring forceps.
5. Traction is applied to the strings to gently remove the IUD from the uterine cavity.
6. Any bleeding is stopped, and the speculum is removed.

4. Qualifying circumstances

CPT 58301 is performed when there is a need to remove an intrauterine device (IUD) from the uterine cavity. This procedure is typically done for contraceptive purposes or when the IUD needs to be replaced. The patient must have an IUD in place that requires removal, and the healthcare provider must be qualified to perform the procedure.

5. When to use CPT code 58301

CPT code 58301 should be used when a healthcare provider performs the removal of an intrauterine device (IUD) from the uterine cavity. It is important to ensure that the procedure is documented accurately and that the code is used only for the specific removal of an IUD.

6. Documentation requirements

To support a claim for CPT 58301, the healthcare provider must document the following information:

• Patient’s medical record indicating the need for IUD removal
• Date and time of the procedure
• Details of the procedure, including the use of speculum and ring forceps
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 58301, ensure that the procedure involves the removal of an intrauterine device (IUD) from the uterine cavity. It is important to follow the specific guidelines provided by the payer and use the appropriate modifiers if required. CPT code 58301 should not be reported with other codes unless additional procedures are performed during the same encounter.

8. Historical information

CPT 58301 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 gynecologist performing the removal of an IUD for a patient who wishes to discontinue contraception.
2. A family medicine physician removing an IUD that has reached the end of its effectiveness for a patient.
3. An obstetrician-gynecologist performing the removal of an IUD due to complications or side effects experienced by the patient.
4. A nurse practitioner removing an IUD for a patient who desires to switch to a different contraceptive method.
5. A reproductive endocrinologist removing an IUD as part of a fertility treatment plan for a patient.
6. A healthcare provider removing an IUD that has become dislodged or expelled from the uterine cavity.
7. A gynecologist removing an IUD for a patient who wishes to become pregnant.
8. A nurse midwife performing the removal of an IUD for a patient who has reached the end of her reproductive years.
9. An obstetrician-gynecologist removing an IUD for a patient who has developed an infection or pelvic inflammatory disease.
10. A family medicine physician removing an IUD for a patient who has experienced allergic reactions or adverse effects to the device.