CPT Code for Nexplanon: Updated Coding Rules for OB-GYN Practices

The amount of OB-GYN practices implementing Nexplanon implants as part of their Reproductive Health services has greatly increased. Nexplanon is a LARC (Long acting reversible contraception). Thanks to Nexplanon, patients can obtain a reliable birth control solution for up to three years, and forget about any maintenance for that time. Yet, providing this service comes with quite a few coding and reimbursement challenges that OB-GYN practices need to navigate. This blog will focus on intricate details and updated rules surrounding coding for OB-GYN practices and Nexplanon implants.

What Is Nexplanon and Why It Matters in OB-GYN Coding

Nexplanon is a flexible implant that is placed subdermally. It releases the synthetic hormone etonogestrel, and it is able to prevent pregnancy for a duration of 3 years. This implant, similarly to other, more temporary birth control options like pills or injections, requires a minor medical procedure to insert and remove. This means that all OB-GYN practices need to make sure that their procedural coding is accurate to ensure a smooth revenue cycle and reimbursement from insurance. Having the right coding accompanied with proper documentation will allow practices to be financially viable. More importantly, it will keep them in compliance with all the standards that govern payers and other regulatory bodies.

The Role of CPT Codes in Medical Billing

CPT or Current Procedural Terminology coding system built by the American Medical Association helps create some uniformity relating to the reporting of medical services and procedures on claims forms. Regarding OB-GYN coding for Nexplanon, the CPT code must be related to a particular surgical service provider — as a result, it must be one of the three: insertion, removal, or removal with reinsertion, for proper payment and coding compliance.

Nexplanon CPT codes are located under the Reproductive System Procedure/Contraception section of the CPT manual. These codes communicate to the payers what occurred in the encounter for a more precise reimbursement.

Core CPT Codes for Nexplanon

There are three primary CPT codes, that relate to Nexplanon procedures:

CPT Code 11981: Nexplanon Insertion

An OBGYN uses CPT code 11981 when a patient gets a Nexplanon implant inserted in her arm. This code describes the work involved for the provider to do the “Insertion, non-biodegradable dare delivery implants” procedure. This includes preparation of the patient, local anesthesia, insertion of the implant, and the dressing after the procedure.

CPT code 11981 does not cover the device itself which is an additional retail cost, and is captured through a separate HCPCS code. Still, 11981 does cover all the clinical care associated solely with the insertion.

CPT Code 11982: Nexplanon Removal

CPT 11982 is used when a patient needs the Nexplanon implant removed. This can be after the implant has been effective, due to side effects or for any other medical reason. The code is described as “Removal, non-biodegradable drug delivery implant.”

The code 11982 is used for removals regardless of how simple or how complicated the removal is. If a removal is particularly complicated, then documentation might be justified to use a .22 modifier which means unusual or increased procedural services. Even in that case, the primary procedure code would still be 11982

CPT Code 11983: Removal With Reinsertion

CPT code 11983 is used when the Nexplanon has been removed and then a new one needs to be inserted in one encounter. This is also referred to as an “exchange.” This means under CPT guidelines, you cannot bill 11982 and 11981 separately for the same visit, so 11983 is used instead; this is a bundled composite service.

HCPCS Code for the Nexplanon Device

Along with CPT codes, you need to use a separate HCPCS Code, or Healthcare Common Procedure Coding System, to classify the implant device. For Nexplanon, the HCPCS code is J7307. An example description for this code is, “Etonogestrel (contraceptive) implant system, including implant and supplies.”

Unlike CPT codes, HCPCS codes contain information on drugs, devices, and supplies. Billing the J7307 code when a practice buys a Nexplanon implant and associated supplies ensures that the practice will get paid for that device, along with the clinical service described with the CPT code.

ICD-10 Diagnosis Codes to Support Nexplanon CPT Codes

The use Accurate ICD-10-CM diagnosis codes are a required component of a CPT/HPCPS code on a claim, and are used to prove that there is a medical necessity for the procedure. The applicable codes in this situation are:

• Z30.017 – Encounter for initial prescription of implantable subdermal contraceptive (used with insertion, CPT 11981).
• Z30.46 – Encounter for checking, reinsertion, or removal of implantable subdermal contraceptives (used with codes 11982 and 11983).

Using specific diagnosis codes, instead of vague or general descriptions, helps lessen the chances of the claim being denied and helps to keep the procedure in line with the clinical circumstances described in the record

Modifiers: When and How to Use Them

Modifiers are two-digit codes appended to CPT or HCPCS codes to clarify special circumstances of a service. For Nexplanon, the most common modifiers include:

Modifier –25

This modifier is used when an evaluation and management (E/M) service is performed that is significant and independent from the procedure performed on the same date. For example, a patient comes in to see you for a problem oriented visit (e.g. irregular bleeding) and you decide to remove the Nexplanon implant after an appropriate evaluation and discussion. You may code the E/M service with a modifier 25 in addition to the procedure code. Your documentation, however, must indicate that the two services are distinct and separate.

Modifiers –52 and –53

There are some circumstances when an insertion attempt for Nexplanon must be abandoned, and the procedures are indicated as reduced or discontinued. Modifiers for such circumstances would be:

• -52: This modifier is for a service that has been reduced and may be used when an attempted insertion is incomplete for technical reasons.
• -53: This modifier indicates that the procedure has been discontinued for clinical reasons, such as safety of the patient. You should check with the payer before using either of these modifiers since guidelines are different for each payer.

Modifier –22 (Increased Procedural Services)

While not specific to Nexplanon, modifier -22 could be used for removal, should it be more complicated than usual (e.g., deeply embedded implant). Modifier -22 can lead to a higher reimbursement if a procedure required more work, removing and substantiating with extensive documentation why it required more work. Always review a payers rules pertaining to modifier -22, as some payers do not accept it.

Documentation Best Practices

Incredible documentation complements clinical quality and coding accuracy. With Nexplanon Services, your documentation must include:

• Explain Medical Necessity: Why was the implant inserted, removed, or exchanged? (e.g., contraceptive choice, side effects, patient preference).
• Include Consent and Counselling: Discussed the risks, benefits, and alternatives, and obtained consent.
• Elaborate on the Clinical Findings and Decision-Making Processes: Explain everything. If E/M services with modifier -25 are billed together, the documentation must include a history, assessment, and a standalone plan different from the procedure note.
• Detail the Procedure: Steps taken to prep the site, anesthesia used, the location of the implant, any difficulties encountered during the procedure, the serial number of the device (if tracked), and the instructions provided after the procedure.

Common Coding Errors and How to Avoid Them

Even the most seasoned Nexplanon coders may go through some trial and error. Common mistakes include:

Billing 11981 and 11982 Together for Removal + Insertion

Some coders used to bill both 11982 (removal) and 11981 (insertion) for the same visit. This is wrong as the correct code for the scenario is 11983. The individual codes will most likely be denied or underpaid.

Incomplete or Missing Diagnosis Codes

More often than not, the practice bills the CPT code without corresponding ICD-10 code. Without a diagnosis (for example, Z30.017 or Z30.46), the payer is likely to state that a claim is not medically necessary. Correcting diagnosis code will help avoid claim denial.

Missing Modifiers for Separate E/M Services

Not adding modifier -25 when an E/M service is deemed separately identifiable is nominal, leading to the inadequate payment problem that coders must work around. The E/M service must not be done for the same purpose, and must be done in different encounters. It must be documented that the service was done separately in order to justify, otherwise, the claim is not likely to go through.

Payer Considerations and Reimbursement Policies

The type of insurance you hold can have an effect on coding and reimbursement:

• Commercial Policies: Most ACA-compliant plans qualify for coverage of Nexplanon insertion and removal. As a preventative service, there is no cost-sharing for the patient. To qualify for this benefit, you must have the correct preventative ICD-10 and CPT codes.
• Medicaid: Each state has different rules, and some may require prior approval or other documentation. Always confirm prior to a service what state-specific Medicaid rules are in effect.
• Medicare: Typically covers little. Because Nexplanon is a device, Medicare only covers it if considered medically necessary. That requires a lot of documentation and justification.

Since payers have different policies, practices properly educate patients on the expected out-of-pocket amounts if coverage is ambiguous and verify benefits before the visit.

Integrating Nexplanon Coding Into Practice Workflows

With the appropriate training of staff in CPT, HCPCS, and diagnosis coding, OB-GYN practices will likely decrease claim denials for Nexplanon. Reporting checklists for coding and modifiers report standardization. Auditing claims on a consistent basis reveals patterns of denials and lacking documentation. Effective collaboration between clinicians and coders, along with comprehensive, unobscured documentation, improves coding, compliance, and reimbursement results