Thursday, July 28, 2011

Contraceptive Choices… What they are, how they work, how to Code for them

Contraceptive Choices… What they are, how they work, how to Code for them

Contraception coding can be a challenge as coders are confronted with procedures that are new, and include devices in addition to the procedure code.

Let’s take a look at some of these options that are currently available for patients.

Occlusive devices used in contraception for women and men can be used to prevent pregnancy. These are devices that occlude the fallopian tubes or Vas deferen tubes and do not allow the egg or sperm to pass through the tube(s).

Let’s look at CPT code 58565 - Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants. This is a permanent form of birth control, and is NOT reversible. The physician performs the hysteroscopy, and places flexible spring-like inserts into the fallopian tube. (most commonly known as the “Essure device”. The very tip of the device remains outside the fallopian to which allows the physician to visually confirm placement of the device. The physician places one of the devices in each of the fallopian tubes. The body will then form scar-tissue around the device, blocking an egg from traveling through the fallopian tube. It usually takes approximately 3 months for the body to build up this scar tissue, which then your physician will confirm by performing a dye test,. and/or an ultrasound to ensure that both inserts are in place, and the tubes are completely blocked. There are no hormones involved in this type of procedure, so menstrual cycles will continue as normal.

Another procedure that is similar and can be used is CPT code 58615 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach. In this procedure, a hysteroscopy is not utilized. This code should be used when a physician performs tubal occlusion without the use of the hysteroscope. A commonly used device with this procedure is the Filshie Clip. The Filshie clip device is placed around the tube/ It works by flattening and crushing the tube between the device, therefore preventing the egg from traveling through the tube. Some physicians also utilize a band/tie that works in nearly the same manner, by squeezing the tube tightly, and not allowing an egg to travel through the tube. This procedure is normally performed as outpatient surgery, but can be performed in an office surgical setting. This procedure is considered permanent, but some patients have had the clips removed, to try and achieve pregnancy.

There are no hormones involved in these type of procedures, so menstrual cycles will continue as normal. The diagnosis code to be used is code V25.2


Women now have a couple of different options regarding what is termed “implanted devices”. These are IUD’s and Contraceptive Capsule/rods.

“Implanon – Capsule Rods”
A new implantable device for contraception is known as the “Implanon” device. This is a small capsule/rod that is implanted subdermally and dispenses a long-acting hormone (etonogestrel) that provides up to 3 years of contraception. This is a reversible contraceptive measure. The hormone in the capsule does affect the menstrual cycle. This procedure(s) is normally performed in the office. In addition, HCPCS code: J7307 (Etonogestrel (contraceptive) implant system, including implant and supplies) should be billed in addition to the procedure code
Coders should keep in mind that CPT has a combination-code for removal & insert at the same time, so it is not appropriate to bill an insert code and a removal code in lieu of using the combination code. ICD-9 code V25.2 and v25.5 are the appropriate diagnosis code to be used
11981 Insertion, non-biodegradable drug delivery implant
11982 Removal, non-biodegradable drug delivery implant
11983 Removal, with reinsertion, non-biodegradable drug delivery implant
11975 Insertion, implantable contraceptive capsules
11976 Removal, implantable contraceptive capsules
11977 Removal, with reinsertion, implantable contraceptive capsules
IUD’s – Intra-Uterine Device
IUD’s work on the premise of implanting an “irritative” device within the uterus. These devices have been around since the 1970’s, and can be wrapped in copper, or contain hormone to prevent pregnancy. A copper wrapped device , such as a Paragard) can stay implanted in the Uterus up to 10 years. The copper on the device is toxic to sperm, therefore the uterus is an inhospitable environment for fertilization. The hormone containing device (such as a mirena) can be in place for up to 5 years, and works by making the mucus in the cervix thick and sticky, and keeps the lining of the uterus from becoming thick making the uterus inhospitable for fertilization. In addition, the hormones in the device also reduce menstrual bleeding and cramping. This is a reversible contraceptive. .
The CPT codes for IUD removal and insertion are:

 58300 Insertion of intrauterine device (IUD)
 58301 Removal of intrauterine device (IUD)

CPT does not have a “combination” code for the removal and re-insertion of an IUD. If a removal and re-insertion are performed on the same day, Coders are to bill for both codes and append a 51 modifier (multiple procedures performed at the same session) to the second procedure. These codes are not bundled in the CCI edits. In addition, you may need to add the HCPCS supply codes for the device in addition the the procedure.
ICD-9 codes V25.1 for insertion and then V25.42 should be used for the removal of the device.
 J7300 Intrauterine Copper contraceptive (Paragard)
 J7302 Levonorgestrel-releasing intrauterine device (Mirena)

Not all contraceptive procedures are performed on women. For men, a vasectomy can be performed. It is considered a permanent method of contraception. However, has been reversed with success. The vasectomy procedure prevents the release of sperm, therefore an egg cannot be fertilized. The procedure requires the physician to occlude, or cut the vas deferens from each testicle. The man continues to produce sperm, but they are reabsorbed by the body. This blockage of sperm does not interfere with the production of seminal fluid. Once the procedure is performed, a man will need follow up care to determine if the procedure was successful by submitting a semen or seminal fluid sample to the physician to check for a -0- sperm count. The traditional procedure utilizes a scalpel, however, there is a no-scalpel vas that uses a small clamp with pointed ends that punctures through the skin. In both procedures a clip, cautery, suture, or ligation is performed to complete the vasectomy.

The vasectomy procedure can be performed in an office or outpatient setting, and normally takes 20-30 minutes. The appropriate ICD-9 code for diagnosis is also V25.2

CPT codes for a vasectomy or vas procedure include:
 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
 55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure)

Contraception and E&M
There are many, many more contraceptive choices that are prescribed by physicians Physicians or providers will do a thorough evaluation and management service (E&M)which can be coded from the New/Established patient codes 99201-99215 or the Preventive/Wellness codes 99381 – 99397. The provider should clearly document the contraceptive services rendered during the office visit to substantiate the contraceptive services or counseling provided. The diagnosis code should correspond to the service(s) provided. As a coder, review the V25 series of diagnosis-codes carefully when choosing the diagnosis for contraceptive management, and initiation of a contraceptive plan or procedure.

Prescription contraceptives
 Hormone Patch
 Hormone Pill
 Vaginal Ring
 Hormone Shot
 Cervical Cap or Diaphram

Over the counter contraceptives
Spermicidal Foam Sponge
Spermicidal Vaginal cream or suppository
Condoms (for male and/or female)

Many third party payers do not pay for contraceptive counseling/management or procedures for contraceptive management. In these cases, contact the carriers in advance to verify your patients’ insurance coverage. If coverage is not available or uncertain, be prepared to have the patient sign an ABN (Advanced Beneficiary Notice), and/or request payment in full at the time services are rendered.


Monday, July 25, 2011

Medicare modifier 24 Unrelated E & M service

I found this on-line regarding the usage of Modifier 24. I was struggling to get this info correctly relayed to some coder ??'s earlier this week. This really sums it up well. Enjoy!

Medicare modifier 24 Unrelated E & M service

Modifier 24 Fact SheetDefinition:
• Unrelated evaluation and management (E/M) service by the same physician* during a postoperative period

Appropriate Usage:

• Append modifier 24 to the E/M procedure code.

• Apply modifier 24 to an unrelated E/M services during the post-operative period beginning the day after a procedure, when the E/M is performed by the same physician* during the postoperative period of procedure code with a 10 or 90 day global period.

• Use modifier 24 if documentation indicates that an E/M service performed exclusively for treatment of the underlying condition and not for post-operative care.

• Use modifier 24 on the E/M code when physicians are managing immunosuppressant therapy during the post-operative period of a transplant.

• Use modifier 24 on the E/M code for physicians managing chemotherapy during the post-operative period of a procedure.

• When the same physician* provides critical care during the post-op period the surgery.

Inappropriate Usage:
• Outside of a post-op period, modifier 24 is inappropriate to document an unrelated E/M service the same day as a procedure.

• To document treatment of a wound infection, consider this part of the post-operative care.

• When the surgeon admits a patient to a skilled nursing facility for a condition related to the surgery.

• Documentation does not clearly indicate the E/M was unrelated to the surgery.
Procedure codes:
• G0181-G0182 Care Plan Oversight Supervision
• 92002-92014 E/M Ophthalmology
• 99201-99499 E/M all locations

*Same physician – Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician." The same physician concept also applies when the exact same physician performs services.

Situations occur when multiple surgery modifiers are reported on the claim.
The following is an example of appropriate reporting of both modifiers 24 (Unrelated E/M by the same physician during a postoperative period), and 25 (Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service), on the same E/M code.


A physician performs a major surgery and within the global period sees the patient for an unrelated E/M visit. During this unrelated E/M visit, the physician determines the necessity of a minor surgery or other procedure. This minor surgery/other procedure is separate and identifiable from the E/M and unrelated to the original major surgery. Both the 24 and 25 modifiers are appropriate to add to the E/M code. The 24 modifier is appropriate because the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is also needed to identify that the minor surgery/procedure performed on the same day is separately identifiable from the E/M service. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery.
Understanding the terminology and technology within these systems

As Health Information Management changes from a paper/hard copy record to an electronic format the information we store within that data needs to have a standard recognizable system for use between the many different types of electronic records. Coders have the unique perspective of working with many forms of this data such as patient billing systems, encoders, inpatient and outpatient procedures, medical transcription, diagnosis, data analysis, abstraction in addition to the electronic record itself.

SNOMED-CT is a reference terminology system developed by the College of American Pathologists (CAP) back in January of 2002. The SNOMED CT acronym stands for the Systematized Nomenclature of Medicine-Clinical Terms. This data set of terminology was developed to provide a standardized method of electronic common language that electronic health records (HER) can access and use regardless of the EHR software developer.SNOMED CT is a clinical vocabulary available in nearly any language, not just english. This electronic language can cross map to other electronic formats such as ICD-9CM, ICD-10-CM and ICD-10-PCS and HCPCS.

As medical coding and billing transitions to a standard electronic health record format, the usage of a common medical language and terminology system for data to be transmitted and accessed between health care providers and facilities with different software programs becomes a critical issue. The local hospitals and provider offices need to easily exchange data in a back and forth type of flow.

It is this lack of standardization for data exchanges in health information that have been an on-going barrier to providers and facilities in converting to electronic records in healthcare. It is oftentimes difficult for coders and billers to get complete records of documentation if Provider Smith's office uses "ABC software" and Hospital Alpha uses "XYZ software" and the two 'software languages cannot 'speak' to each other.

The usage of SNOMED as a standardized electronic data format language is supported in ANSI, DICOM, HL& and ISO standards for HIPPA transactions and code sets. The U.S. Department of Health and Human Services, has entered into an agreement with College of American Pathologists for a perpetual license for the core SNOMED CT data product and ongoing updates. With this perpetual license, it allows no cost use within the U.S. by both U.S. government including federal, state, local, and private organizations.

SNOMED-CT can be used for many different types of data collection functions. This listing below was taken from the International Health Terminology Standards Development Organization website ( It is not an all-inclusive list, but really gives you a good idea of how this information can and is being used in the world today.

• Clinical findings/disorders
• Procedures/interventions
• Observable entities
• Body structures
• Organisms
• Substances
• Pharmaceutical/biologic products
• Specimens
• Special concepts
• Physical objects
• Physical forces
• Events
• Environments/geographic locations
• Social contexts
• Situations with explicit context
• Staging and scales

The next issue that we come up to is the cross-mapping of code-sets for SNOMED-CT to ICD-9 and ICD-10 and HCPCS. Reimbursement and billing requires usage of the ICD-9/ICD-10 and HCPCS code sets. Of course, not all cross-mapping is perfect, but the examples below show how the map works. This cross-mapping is usually a behind-the scenes process that happens with an encoder or an electronic billing/coding system.

SNOMED-CT uses an 8-digit numeric system for classifications, whereas ICD-9 uses a 3 digit primary code with a 1-2 digit extender if needed. ICD-10 and HCPCS use both alpha and numeric systems. As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code

20897003 atrophy of breast  611.4 atrophy of breast
78623009 endometritis  615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder  366.34 cataract in degenerative disorders
297106006 primary infertility  628.9 Female Infertility
297106006 primary infertility  606.9 Male Infertility

In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at

How the SNOMED-CT system works is similar to the progression outlined below. The provider/physician may input the term “headache”, and the SNOMED-CT software would go through the process to find the ‘headache term’, then cross-map and interface with an ICD-9/ICD-10 or HCPCS encoder to populate the query with the multiple codes listed for types of headaches. As the coder/biller, you would then need to review your physician/provider documentation to choose the appropriately mapped code from within the Medical record or billing software and apply the most specific diagnosis possible.

SNOMED Clinical Terms process input 
Clinical finding 
Clinical history and observation findings 
General finding of observation of patient 
Symptom 
Pain 
Pain finding at anatomical site
Pain of head and neck region 

At this time the National Library of Medicine has the following mapping projects underway.
• SNOMED-CT to ICD-9-CM (for reimbursement)
• SNOMED-CT to ICD-10-CM (for implementation in 2013)

These cross-map interfaces become more and more important as the medical industry transitions to the ‘electronic’ record for e-prescribing, and data collection, and patient billing/management. The SNOMED-CT standardized clinical terms is just one area that helps make a complex data system much more accessible, for all medical providers of care.