CODING GUIDELINES FOR CONTRACEPTIVES - Effective April 1, 2018 Version 1.60 - Upstream USA
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CODING GUIDELINES FOR CONTRACEPTIVES Effective April 1, 2018 Version 1.60
TABLE OF CONTENTS
Guidelines for Contraceptive Coding
Pages 2-6 01
ICD-10 CM Diagnosis Codes: Encounter for Contraception
page 7 02
Coding for IUD Insertion and Removal Procedures
pages 8-10 03
Coding for Implant (Nexplanon) Insertion
and Removal Procedures
page 9
04
Coding for LARC Complications
page 10 05
Coding for Immediate Post-Partum LARC
page 11 06
Coding for Short-Acting Contraception
pages 12-15
07
Coding for Emergency Contraception
page 16
08
Coding for Sterilization
page 17 09
About Upstream
Page 18 10
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 1GUIDELINES FOR CONTRACEPTIVE CODING 01
Medical codes describe what happened during the visit and establish medical necessity
for why the visit itself and the services provided during the visit were needed. Clinical
documentation is needed to support the codes submitted to a Payer for reimbursement.
Remember – if it is not documented – it can’t be billed! Clinical and billing staff must
work together as a team to ensure exchange of information is timely, services are
promptly billed and paid in full, and any outstanding questions are resolved.
1. Procedures Codes (CPT/HCPCS) – These codes describe what services were provided.
a. CPT: The Current Procedural Terminology (CPT) code set is maintained by the
American Medical Association. Every service we provide relates to a CPT code
including Evaluation and Management (E/M) services, procedures, device
implants and removals, lesion removals, pap smears, lab tests, immunizations etc.
b. HCPCS codes are used to typically describe supplies including: contraceptives,
LARC devices and drugs.
2. ICD-10 Diagnosis Codes – International Classification of Diseases. These codes are
used to describe why the services were provided. They describe conditions, diseases,
injuries, and symptoms. The World Health Organization (WHO) is responsible for
updating ICD codes. Although reimbursement is typically based on procedure codes,
diagnosis codes also must be included on a claim to establish medical necessity and Coding Tip
ensure accurate reimbursement.
Robust documentation
a. It is essential for clinical and billing staff to learn the new ICD-10 code set and practices along with
work together to ensure appropriate reimbursement of services is maintained. correct coding will support
and lead to appropriate
payment of services.
3. Modifier Codes – are used to describe special circumstances pertaining to the CPT
billed. Some modifiers impact payment. Commonly used modifiers for LARC include:
– 22 Increased Procedural Services (not used on E/M)
– 24 Unrelated E/M Service by the Same Physician / QHCP during a postoperative
period
– 25 Distinct E/M from the LARC procedure by same physician / QHCP on same day
– 51 Multiple Procedures – same session and clinician
– 52 Reduced Service
– 53 Discontinued Service
– 59 Separate Procedures or Distinct Procedural Services
– 76 Repeat procedure same physician / QHCP
– 77 Repeat procedure different physician / QHCP
– 79 Unrelated procedure by the same physician / QHCP during the post-operative
period (starting the day after the procedure)
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 2GUIDELINES FOR CONTRACEPTIVE CODING 01
ACOG (American College of Obstetricians and Gynecologists) recommends the following
practices for coding of LARC (Long acting reversible contraception) services:
E/M Services Code Only
If a patient comes in to discuss contraception options but no procedure is provided at that visit:
• If the discussion takes place during an annual preventive visit (99381–99387 or 99391–
99397), it is included in the Preventive Medicine code. The discussion is not reported
separately.
• If the discussion takes place during an E/M office or outpatient visit (99201–99215),
an E/M services code may be reported if an E/M service (including history, physical
examination, or medical decision making or time spent counseling) is documented.
Link the E/M code to ICD-10-CM diagnosis code Z30.09 (General family planning
counseling and advice).
E/M Services Code and Procedure Code
If discussion of contraceptive options takes place during the same encounter as a
procedure, such as insertion of a contraceptive implant or IUD, it may or may not be
appropriate to report both an E/M services code and the procedure code:
• If the clinician and patient discuss a number of contraceptive options, decide on a
method, and then an implant or IUD is inserted during the visit, an E/M service may be
reported, depending on the documentation.
• If the patient comes into the office and states, “I want an IUD,” followed by a brief
discussion of the benefits and risks and the insertion, an E/M service is not reported
since the E/M services are minimal.
• If the patient comes in for another reason and, during the same visit, a procedure is Coding Tip
performed, then both the E/M services code and procedure may be reported.
An E/M code should not
be routinely coded and
If reporting both an E/M service and a procedure, the documentation must indicate a
billed for a scheduled LARC
significant, separately identifiable E/M service. The documentation must indicate either insertion. Documentation
the key components (history, physical examination, and medical decision making) or time is required to support a
spent counseling. separate and distinct E/M
service.
A modifier 25 (significant, separately identifiable E/M service on the same day as a
procedure or other service) is added to the E/M code to indicate that this service was
significant and separately identifiable from the insertion. This indicates that two distinct
services were provided: an E/M service and a procedure.1
1 ACOG LARC Quick Coding Guide 2012; www.acog.org/-/media/Departments/LARC/LARCQuickCodingGuide.pdf
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 3GUIDELINES FOR CONTRACEPTIVE CODING 01
Time
Clinician counseling is a typically a significant part of the visit as the new QFP (Quality
Family Planning Guidelines) from the CDC (Center for Disease Control) and OPA (Office of
Population Affairs) move towards less required exams for contraceptive initiation and
surveillance.
To determine the level of the E/M code (992xx codes) using time, the clinician counseling Coding Tip
must be greater than 50% of the total face-to-face time with the clinician and patient.
If a clinician spends more
Both the total face-to-face time and the amount spent counseling must be documented in
than 50% of a face-to-face
the medical record. Note the “typical times” for a face-to-face encounter below: visit counseling or
coordinating a patient’s
care, the clinician can
AVG. MINUTES SPENT NEW PATIENT ESTABLISHED PATIENT
code the E/M on the basis
(FACE-TO-FACE)
of time. The level of
5 99211 history, physical
examination, and medical
10 99201 99212
decision-making
15 99213 do not matter in selecting
20 99202 this code.
25 99214
30 99203
40 99215
45 99204
60 99205
Discontinued Insertions
Question: How do you recoup the cost of the device when the IUD insertion was
unsuccessful?
Answer: Some payers will pay for the supply of an IUD after a failed attempt. However,
contact the payer to be certain. The payer may have specific coding instructions you’ll
need to follow so their system can recognize that payment should be made separately for
the initial failed attempt and subsequent successful placement. If the payer provides you
with such instructions it is appropriate to comply with their request. It’s always best to get
this in writing. A copy of the operative note may need to be sent with the claim for the
payer to review.
On the other hand, if the payer doesn't cover LARC supplies that failed to be inserted,
contact the manufacturer. Various LARC manufacturers will either send your practice a
replacement IUD or implant or provide a refund. These manufacturers typically have
forms that must be filled out explaining why the device couldn’t be inserted or may
request a short letter that explains the circumstance.
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 4GUIDELINES FOR CONTRACEPTIVE CODING 01 Discontinued Insertions (cont’d) Question2: Can I bill for the discontinued procedure? Answer: Yes. Either modifier 52 Reduced Service or 53 Discontinued Procedure is added to code 58300 (Insertion of IUD) or codes 11981 or 11983 for the Nexplanon insertion. The modifier is used when a procedure is started but discontinued and no other procedure is performed during the visit. Modifier 52 is used if the clinical provider can not finish the procedure for a technical reason (i.e. stenosis) where as - 53 is typically used when the patient’s safety is a concern (i.e. patient has a vaso-vagal episode). These modifiers provide a way to receive partial payment for work performed before the procedure is discontinued. It is not necessary to reduce the fee. The payer will determine the fee for the service (typically 50% payment). The payer may require documentation showing how much work was actually performed. This modifier is also useful because it tells the payer that the procedure was unsuccessful for future contraceptive billing. Ultrasounds Performed to Check IUD Placement Question: Is an ultrasound performed to check IUD placement included in the IUD insertion? Answer: An ultrasound to check IUD placement is coded separate from the IUD insertion (code 58300). However, keep in mind it is not common practice to use ultrasound to confirm placement. Therefore, this should not be routinely billed. Ultrasounds may be used to confirm the location of the IUD when the clinician incurs a difficult IUD placement (e.g., severe pain, uterine perforation, etc.). Consider the following possible codes for the placement confirmation: • Code 76856 (Ultrasound, pelvic [non-obstetric], real time with image documentation; complete) • Code 76857 Ultrasound, pelvic [non-obstetric], real time with image documentation; limited or follow-up • Code 76830 Ultrasound, transvaginal Occasionally, ultrasound is needed to guide IUD insertion. If ultrasound is used, use code 76998 (Ultrasonic guidance, intra-operative) Difficult Insertions Question: How do I bill for a difficult LARC insertion that takes additional time and effort? Answer: The 22 modifier can be reported if the work required to insert an IUD is substantially greater than usual. The 22 modifier can also be reported in the case of an unsuccessful insertion followed by a successful insertion during the same surgical session. A modifier 22 is added to code. Documentation Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 5
GUIDELINES FOR CONTRACEPTIVE CODING 01
must support the substantial additional work and the reason for the additional work, such
as: increased intensity or time, increased technical difficulty of performing the procedure,
severity of patient’s condition, increased physical and mental effort required. Check with Coding Tip
your payers for guidelines.
The new Quality Family
Lab Tests Planning Guidelines
(QFP) from the CDC and
OPA provides specific
Question: Are in-house lab tests such as a Urine Pregnancy Test or UPT (CPT 81025) recommendations including
reimbursed in addition to the contraceptive visit or procedure? testing relating to
contraceptive services
and should be reviewed
Answer: Depending on your facility and contract with each payer, in-house point-of-care
by clinical staff.
tests may be reimbursed in addition to the main service in a fee-for-service setting.
Accurate documentation, coding of the tests and supporting ICD diagnosis codes to support
medical necessity are essential.
See Appendix A for QFP Check List1
1 Family Planning National Clinical Training Center and CDC, April 2014, Checklist for Family Planning and Related Preventive
Services, fpntc.org/sites/default/files/resource-library-files/JobAids_checklists_508.pdf
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 6ICD-10 CM DIAGNOSIS CODES:
ENCOUNTER FOR CONTRACEPTIVE (Z30-) - EFFECTIVE 10.01.2016 02
Z30.0- Encounter for general counseling and advice on contraception
Z30.01- ENCOUNTER FOR INITIAL PRESCRIPTION OF CONTRACEPTIVES
Z30.011 Contraceptive pills, initial prescription
Z30.012 Emergency contraception, prescription
Z30.013 Injectable contraceptive (Depo Provera), initial prescription
Z30.014 IUD, initial prescription (Note: not coded for the actual insertion)
Z30.015 Vaginal ring hormonal contraceptive, initial prescription
Z30.016 Transdermal patch hormonal contraceptive device, initial prescription
Z30.017 Implantable subdermal contraceptive (Nexplanon), initial prescription
Z30.018 Barrier method or diaphragm, initial prescription
Z30.019 Contraceptives unspecified, initial prescription
Z30.02 COUNSELING AND INSTRUCTION IN NATURAL FAMILY PLANNING TO AVOID PREGNANCY
Z30.09 ENCOUNTER FOR OTHER GENERAL COUNSELING AND ADVICE ON CONTRACEPTION
Z30.2 Encounter for sterilization
Z30.4- Encounter for surveillance of contraceptives (includes refills)
Z30.40 ENCOUNTER FOR SURVEILLANCE OF CONTRACEPTIVES UNSPECIFIED
Z30.41 ENCOUNTER FOR SURVEILLANCE OF CONTRACEPTIVE PILLS
Z30.42 ENCOUNTER FOR SURVEILLANCE OF INJECTABLE CONTRACEPTIVE (Depo Provera)
Z30.43- ENCOUNTER FOR SURVEILLANCE OF IUD
Z30.430 Insertion of IUD
Z30.431 Routine checking of IUD
Z30.432 Removal of IUD
Z30.433 Removal and reinsertion of IUD
Z30.44 ENCOUNTER FOR SURVEILLANCE OF VAGINAL RING
Z30.45 ENCOUNTER FOR SURVEILLANCE OF TRANSDERMAL HORMONAL PATCH
Z30.46 ENCOUNTER FOR SURVEILLANCE OF IMPLANTABLE SUBDERMAL CONTRACEPTIVE (INCLUDES
ROUTINE CHECKING, REINSERTION OR REMOVAL OF NEXPLANON
Z30.49 ENCOUNTER FOR SURVEILLANCE OF OTHER CONTRACEPTIVES
Z30.8 Encounter for other contraceptive management
Z30.9 Encounter for contraceptive management, unspecified
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 7CODING FOR IUD INSERTION AND REMOVAL PROCEDURES 03
CPT code 58300 is coded for IUD insertions while 58301 describes the removal of an IUD.
Reimbursement may depend on who is paying for the service (i.e. Medicaid, a commercial insurer or
the patient), the type of facility you are (i.e. a private physician office, a clinic, a federally qualified
health center or FQHC), provider type and contract terms. For example, your agency might be paid
separately for both the insertion and the device, or you may be paid an inclusive threshold rate for
the visit with no carve-out or separate payment for the device.
For failed IUD insertions append either Modifier 52 (Reduced Service) or Modifier 53
(Discontinued Procedure) to code 58300. These modifiers are used when a procedure is started but
discontinued and no other procedure is performed during the visit. Use Modifier 52 to denote a
failed attempt at insertion when the provider cannot complete procedure for a technical reason (i.e.
N88.2 Stricture/stenosis). Use Modifier 53 for a discontinued procedure when the patient is in
severe pain, changes their mind, or if patient safety is a concern (i.e. R55 vasovagal or T83.39A
perforation during IUD insertion). Check with your payer for specific coding instruction.
ICD-10 code Z30.014 Encounter for initial prescription of IUD may be used for a
visit when the patient may decide to have an IUD placed but the insertion is not done. The patient
may need to have the IUD ordered as a pharmacy benefit. Use code Z30.430 when inserting the IUD.
There are new device codes effective January 1, 2016 for both the Mirena and Liletta IUD which
replace the now deleted code J7302. See below.
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Insertion 58300 IUD Insertion Z30.430 Encounter for insertion of an IUD
and Removal 58301 IUD Removal Z30.432 Encounter for removal of IUD
58301 IUD Removal and 51 (or 59 payer Z30.433 Encounter for removal and reinsertion
58300 IUD Insertion dependent) of IUD
Failed Insertion 58300 IUD Insertion 52 or 53* Z30.430 Encounter for insertion of an IUD (plus
see above relevant codes to support documented issues)
E/M (or other medical / counseling 25 As appropriate (Example: Z30.09 if main reason for
service) - Report E/M code only if medical service is contraceptive options counseling
separate and distinct from the before deciding to have the LARC placed)
insertion or removal procedure
Surveillance E/M (or other medical / counseling Z30.431 Encounter for routine checking of IUD
service)
Device J7296 Levonorgestrel-releasing IUD, 19.5 mg (Kyleena) (Note: new code as of 01.01.2018)
J7297 Levonorgestrel-releasing IUD, 52 mg, 3 year duration (Liletta)
J7298 Levonorgestrel-releasing IUD, 52 mg, 5 year duration (Mirena)
J7300 IUD copper (ParaGard)
J7301 Levonorgestrel-releasing IUD, 13.5 mg (Skyla)
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 8CODING FOR IMPLANT (NEXPLANON) INSERTION
AND REMOVAL PROCEDURES 04
Unlike IUD coding, there is one combination CPT code (11983) for the removal and reinsertion
of Nexplanon. Remember, the device itself is not included in the procedure codes and should
be coded separately for reporting and reimbursement purposes.
For failed implant insertion append either Modifier 52 Reduced Service or Modifier 53
Discontinued Procedure to code 11981 or 11983. Use Modifier 52 to denote a failed attempt at
insertion when the provider cannot complete procedure for a technical reason. Use Modifier
53 for a discontinued procedure when the patient is in severe pain, changes their mind, or if
patient safety is a concern. Check with your payer for specific coding instruction.
There are 2 distinct ICD-10 codes (Z30.017 and Z30.46) for implants that went into effect
October 1, 2016.
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Insertion 11981 Insertion, non- Z30.017 Encounter for initial prescription of
biodegradable drug deliver implantable subdermal contraceptive
and Removal
implant (includes the insertion)
11982 Removal, non-
biodegradable drug delivery
implant Z30.46 Encounter for routine checking,
reinsertion or removal of implantable
11983 Removal with reinsertion, subdermal contraceptive
non-biodegradable drug
delivery implant
11981 Insertion, non- 52 or 53* Z30.017 Implant insertion (plus relevant
Failed Insertion biodegradable drug deliver see above codes to support documented issues)
implant
E/M (or other medical / 25 As appropriate (Example: Z30.09 if main
counseling service) - Report reason for medical service is contraceptive
E/M code only if separate and options counseling before deciding to have
distinct from the insertion or the LARC placed)
removal procedure
Surveillance E/M (or other medical / Z30.46 Encounter for routine checking,
counseling service) removal or reinsertion of implantable
subdermal contraceptive
Contraceptive J7307 Etonogestrel (Contraceptive) Implant System, Including Implant And Supplies (Nexplanon)
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 9CODING FOR LARC COMPLICATIONS 05
There are also ICD-10 codes used to document the presence of a LARC device or a related complication.
See additional T8-- ICD-10 codes and instructions for documenting complications.
TYPE ICD-10 CM DIAGNOSIS
Presence of… Z97.5 Presence of (intrauterine) contraceptive device
- Presence of IUD or subdermal contraceptive implant
*Excludes checking, reinsertion or removal of IUD (Z30.43-)
Excludes checking, reinsertion or removal of implant (Z30.46)
Complications… There are three 7th character extensions that are added to the complication codes below
to identify type of encounter:
• A ----- Initial encounter
• D …… Subsequent encounter
• S ….… Sequela
T83.3- Mechanical complication of intrauterine contraceptive device
T83.31x- Breakdown (mechanical) of intrauterine contraceptive device
- Broken or bent arm, expired
T83.32x- Displacement of intrauterine contraceptive device
- Malposition of IUD, Missing IUD String
T83.39x- Other mechanical complication of intrauterine contraceptive device
- Leakage of, Obstruction (mechanical), Perforation, or Protrusion of IUD
T85.- Complications of other internal prosthetic devices, implants and grafts
T85.618- Breakdown (mechanical) of - implant
T85.628- Displacement of - implant
T85.698- Other mechanical complication of - implant
T85.79X- Infection and inflammatory reaction due to other internal prosthetic
devices, implant and grafts
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 10CODING FOR IMMEDIATE POST-PARTUM LARC INSERTIONS 06
The immediate postpartum period – prior to hospital discharge— can be an opportune time to offer
contraception. Insertion of LARC methods immediately postpartum can also provide access to these
methods for women who may not have insurance coverage after delivery or who may not attend their
scheduled postpartum follow up visit.
ACOG provides direct links by state to a 2016 CMS publication: Medicaid Reimbursement for Postpartum
LARC in the Hospital Setting.1 (click here)
• In cases in which the LARC is placed immediately following birth - you would typically append a
Modifier 51 (multiple procedures) or occasionally modifier 59 (distinct procedure) depending on the
payer’s instruction) to the CPT code for the insertion.
• When the LARC is placed 24 hours or more after birth, the insertion CPT (58300 or 11981)
requires the addition of the Modifier -79 Unrelated procedure by the same physician or QHCP during
the post-operative period (starting the day after the procedure) rather than modifier 51 for multiple
procedures done at the same time.
Check with your payers for specific reimbursement instructions for both the device and insertion.
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
IUD 58300 IUD Insertion Z30.430 Encounter for insertion of an IUD
51 or 79 *
see above
Implant 11981 Implant Insertion Z30.017 Encounter for insertion of an implant
Device J7296 Levonorgestrel-releasing IUD, 19.5 mg (Kyleena) (Note: new code effective 01.01.2018)
J7297 Levonorgestrel-releasing IUD, 52 mg, 3 year duration (Liletta)
J7298 Levonorgestrel-releasing IUD, 52 mg, 5 year duration (Mirena)
J7300 IUD copper (ParaGard)
J7301 Levonorgestrel-releasing IUD, 13.5 mg (Skyla)
J7307 Etonogestrel (Contraceptive) Implant System, Including Implant And Supplies (Nexplanon)
1 http://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/Coding-and-Reimbursement-for-LARC/Reimbursement-
Resources-for-Postpartum-LARC-Initiation/Medicaid-Reimbursement-for-Postpartum-LARC-By-State
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 11CODING FOR SHORT ACTING REVERSIBLE CONTRACEPTIVE METHODS 07
Oral contraceptives, vaginal rings, hormonal patches, injections, barrier methods, emergency
contraception (EC) and other forms of short acting reversible contraception dispensed should
be documented and captured for each visit. The cost of the contraceptive supply may be
separately reimbursed in addition to the medical service or counseling. Check with your payers
and contracts for guidelines. Use the ICD-10 diagnosis codes most specific to each method and
if you are initiating or providing surveillance (refill). Avoid using unspecified codes whenever
possible.
Coding for Oral Contraceptives (OC)
TYPE CPT / HCPCS ICD-10 CM DIAGNOSIS
Initial E/M (or other Z30.11 Encounter for initial prescription of OC
medical /
counseling service)
Surveillance E/M (or other Z30.41 Encounter for surveillance of OC
medical /
counseling service)
Contraceptive S4993 Contraceptive pills for birth control - include units
Coding for Depo Provera
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Initiate E/M 992xx or 993xx 25
Z30.013 Encounter for initial prescription of
96372 Injection injectable contraceptive
Surveillance Report E/M only if separate and Z30.42 Encounter for surveillance of injectable
distinct from the injection contraceptive
Contraceptive J1050 Injection, medroxyprogesterone acetate, 1 mg (report units per mg dispensed (i.e. 150 or 104))
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 12CODING FOR SHORT ACTING REVERSIBLE CONTRACEPTIVE METHODS 07
Effective October 1, 2016 there are new specific codes for both the vaginal ring and hormonal
patch. For claims with dates of service prior to this, you would use the unspecified codes
Z30.018 for the initial prescriptions or Z30.49 for the surveillance and refill visits.
Coding for Vaginal Rings
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Initial E/M (or other medical / Z30.015 Encounter for initial prescription of
counseling service) vaginal ring hormonal contraceptive
Surveillance E/M (or other medical / Z30.44 Encounter for surveillance of vaginal
counseling service) ring hormonal contraceptive device
Contraceptive J7303 Contraceptive vaginal ring – include units
Coding for Hormonal Patches
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Initiate E/M (or other medical / Z30.016 Encounter for initial prescription of
counseling service) transdermal patch hormonal contraceptive
device
Surveillance E/M (or other medical / Z30.45 Encounter for surveillance of
counseling service) transdermal patch hormonal contraceptive
device
Contraceptive J7304 Contraceptive hormonal patch – include units
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 13CODING FOR SHORT ACTING REVERSIBLE CONTRACEPTIVE METHODS 07
Coding for Diaphragm, Cervical Cap
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Initial 57170 Diaphragm or cervical cap Z30.018 Encounter for initial prescription
fitting with instructions of diaphragm
E/M (or other medical / 25 As appropriate
counseling service) - Report E/M
code only if separate and distinct
from the procedure
Surveillance E/M (or other medical / Z30.49 Encounter for surveillance of
counseling service) diaphragm
AA261 cervical cap, A4266 diaphragm, Check with Payer for appropriate codes and if separately
Contraceptive reimbursed
Coding for Other Barrier Methods (Sponge, condoms, spermicide)
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Initial E/M (or other medical / counseling Z30.018 Encounter for initial
service) prescription of barrier contraception
Surveillance E/M (or other medical / counseling Z30.49 Encounter for surveillance of
service) barrier contraception
A4267 male condom, A4268 female condom, A4269 contraceptive supply-spermicide. Check with
Contraceptive Payer for appropriate codes and if separately reimbursed
Note: Code Z30.018 applies to female patients only. Use the code Z30.09 for family planning
advice provided to male clients.
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 14CODING FOR OTHER METHODS 07
Coding for Natural Family Planning
TYPE CPT / HCPCS ICD-10 CM DIAGNOSIS
Initial
E/M (or other medical / counseling Z30.02 Counseling and instruction in natural
service) family planning to avoid pregnancy
Surveillance
Contraceptive None
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 15CODING FOR EMERGENCY CONTRACEPTION 08
Emergency contraception methods are used to prevent pregnancy after unprotected sex, rape,
or birth control failure. Methods include:
• Progestin-only pills, combination estrogen-progestin pills, ulipristal pills
• Copper IUD
Coding for ECPs
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
EC E/M (or other medical / counseling Z30.012 Encounter for prescription of
service) emergency contraception
Contraceptive Check with Payers on accepted J or S code
Coding for Copper IUD as EC
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Insertion 58300 IUD Insertion Z30.430 Encounter for IUD insertion
Z30.012 Encounter for prescription of
emergency contraception
(check with payer if both codes are
needed)
E/M (or other medical / counseling 25 As appropriate
service) - Report E/M code only if
separate and distinct from the EC
insertion procedure
Contraceptive J7300 IUD copper – ParaGard
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 16CODING FOR STERILIZATION 09
Coding for Female Sterilization Procedure
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Hysteroscopy 58565 Hysteroscopy, surgical; Z30.2 Encounter for sterilization
with bilateral fallopian tube
cannulation to induce occlusion
by placement of permanent
implants
Other related procedure codes
include: 58600, 58605, 58615
58671…
E/M - Report E/M code only if 25 As appropriate
separate and distinct from the
procedure; Not reported for
scheduled procedures
As appropriate Z98.51 Tubal ligation status
A4264 Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
Contraceptive [Pomeroy technique, Falope ring, Filshie clip, Hulka-Clemens clip]
Coding for Vasectomy Procedure
TYPE CPT / HCPCS MODIFIER ICD-10 CM DIAGNOSIS
Vasectomy 55250 Encounter Vasectomy, Z30.2 Encounter for sterilization
unilateral or bilateral (separate
procedure), including
postoperative semen
examination(s)
E/M (992xx or 993xx) - Report 25 As appropriate
E/M code only if separate and
distinct from the procedure; Not
reported for scheduled
procedures
As appropriate Z98.52 Vasectomy status
Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 17ABOUT UPSTREAM USA 10 Mission Upstream has developed a consulting and technical assistance practice for health centers to ensure that all women have access to a full range of contraceptive methods, particularly the most effective ones, IUDs and implants. Upstream’s goal is to ensure that every child born in America is a planned for and wanted child, so that they can have very best start on life and improve outcomes for generations. Additional information: www.upstream.org ABOUT THIS GUIDE This guide was created as an educational tool only to help providers and administrators better understand the proper codes used to identify and capture common contraceptive services for reimbursement purposes. Recommendations of code selection and claim submission should be based upon medical record documentation for services rendered for each individual encounter. Codes are subject to change. This guide is not intended to endorse any one method of contraception over another. Quality contraceptive care must always be patient-centered and responsive to individual preferences, needs, and values in accordance with the Quality Family Planning Guidelines outlined by the Center for Disease Control (CDC) and the Office of Population Affairs (OPA).1 . 1 Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs, Recommendations and Reports, April 25, 2014, www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm Provided as reference only, codes subject to change, Version 1.60 April 2018 Coding for Contraceptives ⎜ 18
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