Medical Coding Errors led Insurer to Deny State-Mandated Contraceptive Coverage

by | Last updated Dec 8, 2023 | Published on May 9, 2017 | Medical Billing

Medical Coding Errors
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Medical coders in reliable medical billing and coding companies are well aware of the codes to be used when reporting insertion and removal contraceptive implant and intrauterine devices (IUDs). Correct coding will not only ensure appropriate compensation for services but also prevent improper denials by the health insurance company. In fact, when recently fined $1 million for improperly denying state-mandated contraceptive coverage, Excellus Health Plan acknowledged that the denials had occurred due to coding errors.

According to the recent New York Journal report, Rochester-based nonprofit health insurer Excellus Health Plan was fined by NY regulators for wrongful denial of mandatory contraceptive coverage to some consumers between January 2008 and June 2014. Under the contraceptive mandate which was part of Obamacare, most employers were required by the Health and Human Services Department to provide insurance that cover 18 types of FDA-approved contraceptives, including birth control pills or the morning-after pill.

State laws require most group policies in the state to provide coverage for contraception and Excellus was fined for denying the claims of about 1000 individuals. The issues that the health insurer admitted to include:

  • Medical coding mistakes
  • Not paying claims within prescribed deadlines
  • Failing to promptly process the grievances that resulted over nonpayment of benefits

In a stipulation and consent order, Excellus agreed to rectify any outstanding deficiencies and to file a corrective actions report with the state Department of Financial Services (DFS) by August 22.

Accurate and timely OB and gynecology medical billing services are available to ensure appropriate reimbursement and payment for Long Action Reversible Contraception (LARC) utilization. Expert medical teams are well-versed in the appropriate use of CPT-4 and ICD-10-CM for LARC-related services. They will use the relevant American CPT and ICD-10 codes for reporting LARC utilization which are as follows:

CPT codes for the insertion and/or removal of the contraceptive implant:

11981, Insertion, non-biodegradable drug delivery implant
11981 Insertion, implant FAILED (append modifier 53)
11982 Removal, non-biodegradable drug delivery implant
11983 Removal with reinsertion, non-biodegradable drug delivery implant

Though they may vary, diagnostic codes are typically selected from the Encounter for Contraceptive Management code series Z30 in ICD-10-CM:
Z30.018 Encounter for initial prescription of other contraceptives
Z30.49 Encounter for surveillance (checking, reinsertion, or removal) of other contraceptives

It must be noted that cost of the supply is not included in the CPT procedure codes. The supply should be reported separately using the HCPCS (Healthcare Procedural Coding System) code:
J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

CPT codes for reporting the insertion and/or removal of an intrauterine contraceptive device:

58300 Intrauterine contraceptive device insert
58300 Intrauterine contraceptive device insert FAILED (append modifier 53)
58301 Intrauterine contraceptive device removal

Most IUD services are linked to the Z30 series in ICD-10-CM:
Z30.014 Encounter for initial prescription of intrauterine contraceptive device
Z30.430 Encounter for insertion of intrauterine contraceptive device
Z30.431 Encounter for routine checking of intrauterine contraceptive device
Z30.432 Encounter for removal of intrauterine contraceptive device
Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
Z97.5 Presence of intrauterine contraceptive device

The supply of the device is reported separately using one of the following HCPCS codes:
J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration
J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration
J7300 Intrauterine copper contraceptive
J7301 Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg

Reports say that Republicans are looking to eliminate the birth control coverage mandate. However, New York Journal reports that Gov. Andrew Cuomo and state Attorney General Eric Schneiderman, both Democrats, have reiterated that the state would oppose any attempts by the Trump administration to roll back contraceptive coverage by insurers or to limit access to abortion in New York.

To avoid improper denials and ensure optimal reporting of LARC services provided, obstetricians and gynecologists can rely on professional obstetrics medical billing services. This will ensure appropriate code selection and adherence to documentation requirements for reporting preventive health services according to CPT guidelines.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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