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The CPT® Code 58300 refers to the procedure for the insertion of an intrauterine device (IUD), which is a form of long-term contraception. There are two primary types of IUDs available: the copper-releasing device, which prevents sperm from fertilizing an egg, and the hormone-releasing device, which works by thickening cervical mucus and thinning the uterine lining to prevent pregnancy. Prior to the insertion of the IUD, a bimanual examination is conducted to evaluate the position of the uterus, ensuring that the procedure can be performed safely and effectively. This examination is crucial as it helps the healthcare provider determine the appropriate placement of the IUD. Following the examination, the cervix is cleansed to minimize the risk of infection, and a tenaculum is used to stabilize the cervix during the procedure. A uterine sound is then introduced into the uterus to measure the depth of the uterine cavity, which is essential for proper IUD placement. The IUD is prepared for insertion by positioning it in the insertion tube and attaching the insertion rod. The actual insertion involves carefully placing the IUD into the uterus, followed by a slight retraction of the insertion tube to allow the IUD to expand to its full size. Once the IUD is correctly positioned, the insertion rod is removed, and the insertion tube is withdrawn. The threads of the IUD, which are designed to hang through the cervical os for future access, are released automatically. Finally, the tenaculum is removed, and the threads are trimmed to approximately 3 cm in length to ensure they are not excessively long. This procedure is essential for women seeking effective and reversible contraception.
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The insertion of an intrauterine device (IUD) using CPT® Code 58300 is indicated for the following conditions:
The procedure for the insertion of an intrauterine device (IUD) involves several critical steps to ensure proper placement and minimize discomfort for the patient.
After the insertion of the IUD, patients may experience some cramping or spotting, which is typically mild and resolves within a few days. It is important for patients to be informed about potential side effects and to schedule a follow-up appointment to ensure the IUD is properly positioned. Patients should also be advised to monitor for any signs of complications, such as severe pain, heavy bleeding, or unusual discharge, and to seek medical attention if these occur. Regular checks of the IUD threads are recommended to confirm that the device remains in place. Overall, the post-procedure care focuses on monitoring the patient's comfort and ensuring the effectiveness of the IUD as a contraceptive method.
| Short Descr | INSERT INTRAUTERINE DEVICE | Medium Descr | INSERTION INTRAUTERINE DEVICE IUD | Long Descr | Insertion of intrauterine device (IUD) | Status Code | Non-Covered Service | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 9 - Not Applicable | Multiple Procedures (51) | 9 - Concept does not apply. | Bilateral Surgery (50) | 9 - Concept does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 9 - Concept does not apply. | Co-Surgeons (62) | 9 - Concept does not apply. | Team Surgery (66) | 9 - Concept does not apply. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Non-Covered Service, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 0 | CCS Clinical Classification | 131 - Other non-OR therapeutic procedures, female organs |
| GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GC | This service has been performed in part by a resident under the direction of a teaching physician | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AU | Item furnished in conjunction with a urological, ostomy, or tracheostomy supply | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CG | Policy criteria applied | CR | Catastrophe/disaster related | FP | Service provided as part of family planning program | GA | Waiver of liability statement issued as required by payer policy, individual case | GW | Service not related to the hospice patient's terminal condition | GX | Notice of liability issued, voluntary under payer policy | GZ | Item or service expected to be denied as not reasonable and necessary | HN | Bachelors degree level | KX | Requirements specified in the medical policy have been met | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SA | Nurse practitioner rendering service in collaboration with a physician | SB | Nurse midwife | SG | Ambulatory surgical center (asc) facility service | U7 | Medicaid level of care 7, as defined by each state | UA | Medicaid level of care 10, as defined by each state | X1 | Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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