Coding description for CPT code 58300
The physician inserts a speculum into the vagina to visualize the cervix. A tool is used to gently pull down the cervix; it is dilated. For CPT code 58300, an intrauterine device (IUD), any of a variety of shapes (coil, loop, T, 7), is guided into the uterus through an insertion tube placed in the cervical os. In code 58301, to remove a previously placed IUD from the uterus, a device is inserted through the cervical os and used to grasp and remove the IUD.
58300 – Insertion of intrauterine device (IUD)
58301 – Removal of intrauterine device (IUD)
If for any complication the the procedure for insertion of IUD is discontinued or terminated in between, 53 modifier should be appended to the cpt code 58300-53. This will help in proper payment for the procedure or CPT code, missing modifier can lead to denial.
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Sample coded report for CPT 58300
IUD Placement- ParaGard
Patient comes in today for IUD placement. Pregnancy test and other results reviewed. Risks and benefits of the procedure were reviewed with patient. Other appropriate forms of contraception were discussed. The patient wished to proceed. Informed consent was obtained. Written consent given by patient.
Patient is recently post-partum. . The manufacturer’s information and consent were provided to patient including the lot number and expiration date/reminder card.
A pre-procedure time-out was taken. The correct patient, procedure and site were confirmed by the physician, patient and assistant. All neccessary equipment was confirmed to be present.
Premedication given includes: Ibuprofen or other NSAID. Betadine was used to prep cervix. A tenaculum was applied to the cervix. The uterus was sounded to 7 cm. The IUD was inserted under sterile technique in fundus and deployed without difficulty. The strings were trimmed and all instruments were removed from the vagina. Good hemostasis was noted and patient tolerated procedure well. The patient was instructed on follow up and was advised to call for fever, heavy bleeding or severe pain. The patient was instructed to check strings, and take NSAIDS or tylenol if needed.
UPT- negative
Pelvic exam performed. Uterus sounded to 7 cm. IUD placed in normal
fashion. Tenaculum removed. Sites were hemostatic. Strings cut to 3 cm.
IUD position confirmed with TVUS.
Patient tolerated this well.
Reports PP depression is well managed. Denies crying spells
Pelvic rest for 1 week.
RTC in 6 weeks for IUD string check.
CPT 58300
ICD-10 Z30.430 – Encounter for insertion of intrauterine contraceptive device