The CPT Code For IUD Removal Explained (2023) | Description, Guidelines, Reimbursement & Billing Examples
CPT code for IUD removal (58301) bills for service when the physician performs the removal of the intrauterine device (IUD). IUD incorporates into the uterus of a female to control birth, and it is also known as intrauterine contraception (IUC).
The following are reasons why Physician removes the IUD:
- Elevated blood pressure
- Endometrial or cervical cancer
- Post-menopausal
- Infection in the pelvis region
The Physician incorporates a speculum into the vagina to examine the cervix. A tool aids in dilating and down the cervix.
IUD present in various forms such as T-shape, coil, loop, 7. A device may insert into the cervical to retrieve the uterine device.
CPT 58300 reports when the Physician inserts an intrauterine device into a female’s uterus. In contrast, CPT code for IUD removal bills for removal of IUD from the female uterus.
CPT 58300 and CPT code for IUD removal (58301) may be performed by a registered nurse, physician assistant, nurse practitioner, or other trained paramedical under a physician’s supervision.
CPT Code For IUD Removal Description
CPT code for IUD removal 58301 bills for service when the Physician removes the intrauterine device (IUD).
The official description of the IUD removal CPT code 58301 is: “Removal of intrauterine device (IUD).”
Reimbursement
A maximum of one unit can be a bill on the same service date of CPT code for IUD removal 58301. In contrast, the three units allow when documentation supports the medical necessity of the service.
The cost and RUVS of CPT 58301 with modifier 26 are $71.22 and 2.05811 when performed in the facility. In contrast, the reimbursement and RUVS of CPT code for IUD removal 58301 with modifier 26 are $126.52 and 3.65611 when performed in the non-facility.
Billing Guidelines
Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.
CPT 58301 does not allow inserting and removing implantable contraceptive capsules (11976, 11981-11983). These CPT codes are separately reportable. Check insurance guidelines to see if the ModifierModifier is appropriate.
CPT 58300 and CPT code for IUD removal 58301 may perform by a registered nurse, physician assistant, nurse practitioner, or other trained paramedical people under a physician’s supervision.
If IUD removal and insertions perform by the Physician in the same encounter, It is appropriate to report both CPT codes 58300 (Insertion) and 58300 (removal).
Medicare does not separately reimburse surgical trays (A4550); other third-party payers may cover them.
CPT 11976 and 11981 report for service when the Physician prescribes a non-biodegradable drug of the implant for contraception. CPT 11976 reports for reinsertion of a non-biodegradable drug.
IUD cost does not cover CPT 58300 and 58301, and It is appropriate to report with HCPCS level II code J7300. In contrast, Local anesthesia includes in the service.
Reports the HCPCS Level II code for Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg (J7297) or Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg (J7298).
Billing Examples
Below you can find examples of cases when CPT 58301 should be billed.
Example 1
A 25-year-old female presents to the office with endometrial cancer. The patient has had pain in the pelvic region for three to four days.
The patient had recently had the insertion of an IUD device. The patient did take medication but gave relief for a few hours. He was able to eat normally and had a healthy lifestyle.
The patient denies any recent travel, Dizziness, abdominal pain, vomiting, extremity swelling, headache, numbness, chest pain, shortness of breath, and urinary problem.
Diagnostic studies were unremarkable. The physical exam shows swelling in the pelvic region. The Physician ordered a series of diagnostics tests, such as an Ultrasound of the pelvis and vagina. The Physician consulted with the gynecologist and suggested removing the IUD.
The Physician scheduled an appointment for the removal of the IUD. She develops an infection at the site of the intrauterine device. The Physician successfully removes the IUD. The Physician prescribed medicines and scheduled follow-up visits.
Billing:
CPT Codes:
- CPT 99213: Office or other outpatient visit for the evaluation and management of an established patient: This code is used for the patient’s office visit to address her pelvic pain and endometrial cancer.
- CPT 58301: Removal of intrauterine device (IUD): This code removes the patient’s IUD.
ICD-10 Codes:
- ICD 10 C54.1: Malignant neoplasm of endometrium: This code documents the patient’s endometrial cancer diagnosis.
- ICD 10 R10.2: Pelvic and perineal pain: This code documents the patient’s presenting symptom of pelvic pain.
- ICD 10 T83.318A: Infection and inflammatory reaction due to other internal prosthetic devices, implants, and grafts in the genitourinary system, initial encounter: This code is used to document the infection at the site of the intrauterine device.
- ICD 10 Z30.430: Encounter for insertion of intrauterine contraceptive device: This code is used to document the patient’s history of IUD insertion.
Example 2
A 27-year-old female presents to the office with urinary problems, sexual dysfunction, and balance problems. The patient had recently had the insertion of an IUD device. The patient did take medication but gave relief. He was able to eat every day and had a healthy lifestyle.
The patient denies any recent travel, Dizziness, abdominal pain, vomiting, extremity swelling, headache, numbness, chest pain, shortness of breath, and urinary problem.
Diagnostic studies were unremarkable. The physical exam shows swelling in the pelvic region. The Physician ordered a series of diagnostics tests, such as an Ultrasound of the pelvis and vagina. The Physician consulted with the gynecologist and suggested removing the IUD.
The Physician prescribed medicines and scheduled follow-up visits. The Physician scheduled an appointment for the removal of the IUD.
She develops an infection at the site of the intrauterine device. The Physician successfully removes the IUD.
Billing:
CPT Codes:
- CPT 99203: Office or other outpatient visit for the evaluation and management of a new patient: This code is used to assess and manage the patient’s urinary problems, sexual dysfunction, and balance problems.
- CPT 76830: Ultrasound, transvaginal: This diagnostic test is ordered to evaluate the patient’s swelling in the pelvic region and investigate the cause.
- CPT 58301: Removal of intrauterine device (IUD): This code is used to remove the IUD due to the patient’s infection and complications.
ICD-10 Codes:
- ICD 10 N39.3: Stress incontinence (female) (male): This code documents the patient’s urinary problems.
- ICD 10 N94.6: Dyspareunia: This code documents the patient’s sexual dysfunction.
- ICD 10 R26.81: Unsteadiness on feet: This code documents the patient’s balance problems.
- ICD 10 Z30.430: Encounter for surveillance of intrauterine contraceptive device: This code documents the patient’s initial visit to insert the IUD.
- ICD 10 T83.32XA: Infection and inflammatory reaction due to intrauterine contraceptive device, initial encounter: This code is used to document the patient’s infection at the site of the IUD.
Example 3
A 50-year-old female presents to the office in a post-menopausal state. The patient had recently had the insertion of an IUD device. The patient wants to remove her IUD as no more is needed. He was able to eat normally and had a healthy lifestyle.
The patient denies any recent travel, Dizziness, abdominal pain, vomiting, extremity swelling, headache, numbness, chest pain, shortness of breath, and urinary problem.
Diagnostic studies were unremarkable. The physical exam shows no significant findings. The Physician ordered a series of diagnostics tests, such as an Ultrasound of the pelvis and vagina. The Physician consulted with the gynecologist and suggested removing the IUD.
The Physician prescribes medicines and schedules follow-up visits. He scheduled an appointment for the removal of the IUD.
She has a chance of developing an infection at the site of the intrauterine device. The Physician successfully removes the IUD.
Billing:
CPT Codes:
- CPT 99213: Office or other outpatient visit for the evaluation and management of an established patient: This code is used for the patient’s office visit addressing the removal of the IUD.
- CPT 58301: Removal of intrauterine device (IUD): This code is used to represent the removal of the IUD by the physician.
ICD-10 Codes:
- ICD 10 Z30.430: Encounter for surveillance of previously prescribed contraceptive methods, intrauterine contraceptive device: This code documents the reason for the patient’s visit and the need to remove the IUD.
- ICD 10 Z97.5: Presence of (intrauterine) contraceptive device: This code documents the patient’s current use of an IUD.
Modifier:
- Modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: This modifier is used to indicate that the office visit and the removal of the IUD were separate and distinct services provided to the patient on the same day.
Example 4
A forty-three-year-old female presents to the office with no signs and symptoms of female genital organs patient had recently had the insertion of an IUD device. She wants to eliminate her IUD to have a baby in the future. He was able to eat normally and had a healthy lifestyle.
The patient denies any recent travel, Dizziness, abdominal pain, vomiting, extremity swelling, headache, numbness, chest pain, shortness of breath, and urinary problem.
Diagnostic studies were unremarkable. The physical exam shows no significant findings. The Physician ordered a series of diagnostics tests, such as an Ultrasound of the pelvis and vagina. The Physician consulted with the gynecologist and suggested removing the IUD.
The Physician prescribes medicines and schedules follow-up visits. The Physician scheduled an appointment for the removal of the IUD.
Billing:
CPT Codes:
- CPT 99213: Office or other outpatient visit for the evaluation and management of an established patient: This code is used for the office visit addressing the patient’s request to remove the IUD.
- CPT 58301: Removal of intrauterine device (IUD): This code is used for removing the IUD, which will be scheduled for a future appointment.
ICD-10 Codes:
- ICD 10 Z30.430: Encounter for intrauterine contraceptive device insertion: This code is used to document the patient’s history of IUD insertion.
- ICD 10 Z30.2: Encounter for surveillance of contraceptives, intrauterine device: This code is used for the follow-up visit related to the patient’s IUD.
Example 5
A 40-year-old female presented to the office with pelvic pain and had elevated blood pressure. The patient had recently had insertion of an IUD device. The patient blood pressure was around 140/100. She did not take any drugs for blood pressure. The patient did take medication but gave relief for a few hours.
The patient denies any recent travel, Dizziness, abdominal pain, vomiting, extremity swelling, headache, numbness, chest pain, shortness of breath, and urinary problem.
Diagnostic studies were unremarkable. The physical exam shows swelling in the pelvic region. The Physician ordered a series of diagnostics tests, such as an Ultrasound of the pelvis and vagina. The Physician consulted with the gynecologist and suggested removing the IUD.
The Physician prescribes medicines and schedules follow-up visits. The Physician scheduled an appointment for the removal of the IUD.
She develops an infection at the site of the intrauterine device. The Physician successfully removes the IUD.
Billing:
CPT Codes:
- CPT 99213: Office or other outpatient visit for the evaluation and management of an established patient: This code is used for the initial office visit addressing the patient’s pelvic pain and elevated blood pressure.
- CPT 76856: Ultrasound, pelvic (nonobstetric), real-time with image documentation; complete: This diagnostic test is ordered to evaluate the patient’s pelvic pain and swelling.
- CPT 76830: Ultrasound, transvaginal: This diagnostic test is ordered to further evaluate the patient’s pelvic pain and swelling related to the IUD.
- CPT 58301: Removal of intrauterine device (IUD): This code is used for the removal of the IUD due to the infection.
ICD-10 Codes:
- ICD 10 N94.89: Other specified conditions associated with female genital organs and menstrual cycle: This code is used to document the patient’s pelvic pain.
- ICD 10 I10: Essential (primary) hypertension: This code is used to document the patient’s elevated blood pressure.
- ICD 10 Z30.430: Encounter for surveillance of intrauterine contraceptive device: This code is used for the follow-up visit related to the IUD.
- ICD 10 T83.318A: Infection and inflammatory reaction due to other urinary device, implant, and graft, initial encounter: This code is used to document the infection at the site of the intrauterine device.
