Thursday, May 3, 2012

Pessary coding - Info from ACOG

ACOG recently put this out, and I felt it worthy to share... 

Coding and Billing for Pessaries

Two codes should be submitted on the 1500 claims form – one for the actual fitting and insertion of the pessary, and a second code for the pessary itself.

To report the initial fitting and insertion of the pessary or other intravaginal device, report CPT-4 code 57160. The supply of the new pessary may be reported separately with either HCPCS code A4561 (Pessary, rubber, any type) or A4562 (Pessary, non rubber, any type). In most cases, physicians are using non-rubber (silicone) pessaries and code A4562 should be reported. Please check with the vendor and/or package description if there is any question as to whether the pessary is rubber or non-rubber (silicone). Note: Non-Medicare carries may accept CPT code 99070 (Supplies and materials, provided by the physician over and above those usually included with the office visit or other services rendered) for the supply of the pessary instead of the HCPCS codes. Check with the payer before reporting.

According to CMS, pessaries can be provided to Medicare beneficiaries by properly enrolled Medicare Suppliers on the receipt of a valid prescription order from a physician. However, the beneficiary cannot "order" a Medicare-covered Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item and then submit a claim to Medicare and expect reimbursement. The Medicare program pays the DMEPOS Supplier directly upon submission by the Supplier of a valid claim.

According to a CMS representative, “If the pharmacy that you are purchasing the pessary from participates with Medicare they should submit a claim for the patient to Medicare (local carriers) for the item. If the patient is going to a pharmacy that is not enrolled with Medicare the patient will not have a method of being reimbursed so it is best to make sure they are going to a pharmacy that is enrolled with Medicare”.

Coding for pessary removal:

If a patient comes into the office to have her pessary removed, cleansed, and reinserted, an appropriate evaluation and management code (99211-99215) should be reported, based on the key components performed (history, examination, and medical decision making), as this is considered part of the E/M service.

If a patient presents to your office for the removal of an impacted pessary, it is appropriate to report CPT-4 code 57415 (Removal of impacted vaginal foreign body under anesthesia). However, if this is performed without anesthesia, report an E/M code at the appropriate level instead. Report ICD-9 diagnosis code 996.39 (Mechanical complication of genitourinary, other) in addition to the patients other conditions such as 616.10 [Vaginitis], or 618.2-618.4 [Cystocele with uterine prolaspe].
You can also access this article from the ACOG website at

1 comment:

  1. I have information that states physicians no longer need to write prescriptions for the pessary device for Medicare patients. We no longer need to provide a DMERC number in order to be reimbursed. We are able to bill A4562 with the appropriate E&M