Does pregnancy or malpositioned IUD come first? None of these studies are able to clarify if it is low placement of the IUD that leads to increased risk of pregnancy or if the pregnancy itself causes malpositioning of the IUD. It is also not known if other types of malpositioning, such as arms extending into the myometrium, are associated with any greater risk of pregnancy. Finally, because there are no prospective studies that have followed a cohort of women with IUDs in situ and assessed pregnancy status according to IUD position, we do not have any data on the absolute risk of pregnancy with a malpositioned IUD in place, though it is likely very small.
IUD type makes a difference. The LNG-IUS does not appear to pose the same risk of pregnancy as copper IUDs if malpositioned. The LNG-IUS prevents pregnancy primarily through hormonal effects on the cervical mucus and endometrium. It seems that the local effects of levonorgestrel are likely adequate for contraception even if the device is not at the fundus, as long as it remains within the uterine cavity. This hypothesis is supported by a randomized clinical trial in which researchers compared the efficacy of an intracervical device that releases the same dose of levonorgestrel as the LNG-IUS, with the efficacy of an LNG-IUS placed at the fundus.7 This study demonstrated no difference in pregnancy rates between the intracervically and the fundally positioned devices.
You also may worry that a downwardly displaced IUD represents risk for expulsion. Although two small studies have suggested that IUDs positioned more than 3 mm from the fundus might have a higher risk of expulsion, most downwardly displaced IUDs are not expelled.8,9 Removal and replacement of downwardly displaced IUDs for the purpose of preventing expulsion would result in a large number of unnecessary removals. Also, studies have shown that not all downwardly displaced IUDs remain so. In fact, the vast majority of IUDs that are downwardly displaced shortly after insertion move to a fundal position within 3 months.10,11
Can malpositioning be avoided?
It is not clear to what extent prevention is possible. Risk factors for IUD malpositioning were examined in a recent case-controlled study. Its authors found that suspected adenomyosis increased the risk of IUD malpositioning and that prior vaginal delivery was protective. No effect of delayed postpartum insertion was seen. The authors also found that public or no insurance was associated with an increased risk of malpositioning; they suggest that this may be related to higher rates of insertion by trainees. Indeed, other studies have found that IUD complications, such as failed insertion and early removals due to pain or bleeding, are associated with insertion by less experienced providers12,13; more skilled providers experience lower rates of IUD malpositioning. Enhancing IUD insertion training may decrease the risk of malpositioning; however, a learning curve may remain.
Despite the fact that some women may be at higher risk for IUD malpositioning, it does not mean they are not IUD candidates. It may be prudent to consider US guidance for IUD insertion in cases of:
- a previous difficult insertion
- obesity precluding the accurate assessment of uterine position, or
- suspected abnormal or distorted uterine cavity.
Integrating evidence and experience
The greatest risk for pregnancy may be unnecessary removal of an IUD. In a recent case-controlled study, Braaten and colleagues compared 182 women with malpositioned IUDs noted on US with 182 women found to have normally positioned IUDs on US. An important finding of this study was that women initially found to have a malpositioned device had a higher rate of pregnancy in the subsequent 2 years. There were no pregnancies among women with malpositioned IUDs left in place; rather, the higher pregnancy rate was due to higher rates of IUD removals (approximately two-thirds of malpositioned IUDs were removed), without replacement with another highly effective method of contraception.
While findings from earlier studies suggest there may be a small increased risk of pregnancy with a malpositioned copper IUD left in situ, as compared with a fundally placed device, this study demonstrates that the real-life risk of pregnancy with removal of an IUD and use of less effective methods of contraception is significantly higher.
Clinicians should be cognizant of this risk prior to removal of a malpositioned IUD and try to ensure that, if a malpositioned IUD is removed, it is quickly replaced with another highly effective form of contraception, such as another IUD, subdermal implant, or sterilization.
Reimbursement for your IUD insertion, and reinsertion, work
Coding for insertion of intrauterine devices (IUDs) can be a hassle if you aren’t familiar with the right code combinations. Here is some advice you can use right now to ensure reimbursement for the usual and unusual situations.
If the purpose of the visit is insertion of an IUD, you only code for that insertion plus the supply. (Even if patient history is repeated at the visit, a separate significant E/M service is not warranted.) Coding is 58300 and J7300 for a copper IUD or J7302 for a levonorgestrel-containing IUD. Note, however, that Blue Cross/Blue Shield payers may require the HCPCS code S4989 (Contraceptive IUD [eg, Progestacert], including implants and supplies), rather than the CPT code.
If you require ultrasound guidance in placing the IUD, the code 76998 can be reported as well.
In some cases, the patient may have a stenotic cervix; if cervical dilation is performed that too can be billed using either 57800, Dilation of cervical canal, instrumental (separate procedure) or 59200, Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure). Because both of these codes are CPT “separate procedures,” a modifier -59 should be added to indicate that a distinct procedure was performed.
In cases in which the IUD is placed immediately following birth, 58300 can be billed but will require a modifier -51. When the IUD is placed 24 hours or more after birth, 58300 requires the addition of the modifier -79 (Unrelated procedure or service by the same physician during the postoperative period).
Sometimes the insertion does not go as planned. If insertion:
- fails due to cervical stenosis, report 58300 with a modifier -52 (Reduced services) since, after considerable work is performed, the decision is made to not insert the device.
- must be stopped because of an unexpected physical reaction by the patient (fainting or a sudden increase or drop in blood pressure), a modifier -53 (Discontinued procedure) is more appropriate.
- is successful but the IUD is expelled from the uterus, repeat insertion may be performed by adding a modifier -76 (Repeat procedure) to 58300.
- is successful but the IUD perforates the uterus to lodge in the abdominal cavity and laparoscopic surgery is required to remove it, the correct code is 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum). Be sure to compare the work to code 49402, (Removal of peritoneal foreign body from peritoneal cavity) to ensure fair reimbursement.
—Melanie Witt, RN, CPC, COBGC, MA
Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American Congress of Obstetricians and Gynecologists.