Health Information Management

Case study

JustCoding News: Outpatient, October 7, 2009

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Operative report for intrauterine device (IUD) insertion

Prior to beginning the procedure, I reviewed with the patient the risks and benefits of the IUD. I asked the patient whether she had any additional questions or concerns, and she stated that she did not. The patient chose to have a nonhormone copper IUD placed (Paragard®).

Informed consent was obtained and signed by both the patient and myself. Oral administration of 800 mg of ibuprofen one hour before insertion was confirmed. I then re-reviewed the instructions with the patient for how to locate the threads within the vagina that are attached to the IUD after each menstrual cycle. The patient is to call the office immediately if she is unable to locate the threads.

The patient was prepped and gowned for surgery. The patient was placed on the exam table, and her feet were placed in the stirrups. The cervix and vaginal fornices were cleansed liberally with Chlorhexidine gluconate (Hibiclens) as per routine protocol. I then stabilized the cervix with a tenaculum. Local anesthesia of 5% lidocaine gel (Xylocaine) was placed in the cervical canal.

I then sounded the uterus to determine the depth of the uterine cavity. I sounded the uterus to a depth of 8 cm. The IUD was then removed from the sterile packaging and prepared for insertion as per manufacturer instruction.

I inserted the IUD into the uterus until the insertion flange was against the cervix. The clear inserter tube was pulled back on the insertion rod approximately 2 cm. The arms of the IUD then spread to the ‘T’ position. The inserter tube was then slowly advanced to correctly position the IUD within the uterine cavity. The insertion rod was removed, followed by the insertion tube. I then released the cervical tenaculum. The IUD threads were cut to a length of approximately 3 cm. This was then noted in the patient chart.

No complications were noted. Patient is to schedule a follow-up visit with me after her next menstrual period to re-check the threads.

For this procedure, report the following codes:

  • CPT code 58300 (for physician/office)
  • ICD-9 procedure code 69.7 (for hospitals)
  • ICD-9 code V25.1
  • HCPCS code J7300 (Intrauterine copper contraceptive)

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