Susan Posted Mon 28th of November, 2016 13:12:09 PM
IUD removal unable to be completed in office due to partially embedded in endometrium. Many attempts and ultrasound done. Can I still bill 58301 or is this just an office visit?
SuperCoder Answered Tue 29th of November, 2016 02:34:42 AM
Greetings from SuperCoder.com!
Please note that this is not just an office visit. Patient was scheduled for IUD removal and physician did her/his best but since it was embedded in endometrium, it could not be removed. In this case, you should report CPT code 58301 and don't forget to append modifier 53 (Discontinued Procedure). This modifier is used when a procedure is started but discontinued and no other procedure is performed during the visit.
Please feel free to write if you have any further questions.