Chelsey Posted Tue 21st of May, 2019 10:42:22 AM
IUD was removed in office but one of the arms was missing. Would I code it 58301 or 58301 mod 52 w/ T83.31XA?
SuperCoder Answered Wed 22nd of May, 2019 06:28:14 AM
Thank you for your question.
You should code removal with CPT® code 58301 (Removal of intrauterine device [IUD]). If this is a routine removal, you should link this code with Z30.432 (Encounter for removal of intrauterine contraceptive device).
Another scenario- If the remaining of the IUD was also removed on the same day or next day; you should append modifier-78 with your CPT® code (58301) along with ICD-10 code T83.31XA.
If your ob-gyn is removing the IUD because of a complication, consult your documentation. You might use complication codes. Some examples include:
T83.31XA (Breakdown [mechanical] of intrauterine contraceptive device, initial encounter)
T83.32XA (Displacement of intrauterine contraceptive device, initial encounter)
T83.39XA (Other mechanical complication of intrauterine contraceptive device, initial encounter)
Hope it helps!