CPT Code 58300 Complete Billing & Coding Guide for Corpus Uteri

Accurate CPT coding is essential for OBGYN practices to ensure compliance, minimize claim denials, and secure appropriate reimbursement. CPT 58300 is used to report the insertion of an intrauterine device (IUD) - a common in-office gynecologic procedure for long-term reversible contraception.

Since this is a frequently performed service in both private and hospital-based OBGYN settings, understanding the correct billing rules, documentation requirements, and payer variations is crucial for maximizing reimbursement and maintaining compliance.

CPT Code 58300 – Description

Official Definition: “Insertion of intrauterine device (IUD).”

This code is used when a provider places an IUD (hormonal or non-hormonal) into a patient’s uterus for contraceptive or therapeutic purposes. The procedure involves placing a sterile speculum, visualizing the cervix, and using a uterine sound to measure depth before inserting the IUD through a special applicator into the uterine cavity.

Description of the Procedure

During the procedure, the patient is typically positioned in lithotomy. After preparing the cervix and vagina with an antiseptic solution, the provider may use a tenaculum to stabilize the cervix. The uterine cavity is measured with a sound to ensure appropriate depth for insertion. The IUD is then loaded into an insertion tube and advanced through the cervical canal into the uterus. Once correctly positioned, the device is released, and the strings are trimmed. The procedure usually takes less than 10 minutes and is typically performed in an office or outpatient setting.

Devices Included Under CPT 58300

CPT 58300 applies to the insertion of both hormonal IUDs (e.g., Mirena®, Liletta®, Kyleena®, Skyla®) and non-hormonal IUDs (e.g., Paragard®). The code only covers the insertion procedure, not the cost of the device itself. The device must be billed separately using the appropriate HCPCS code.

When to Use CPT 58300

CPT 58300 should be reported when the provider performs an IUD insertion for:

• Contraceptive management (hormonal or copper IUD)
• Treatment of heavy menstrual bleeding (with levonorgestrel IUDs)
• Endometrial protection in patients on estrogen therapy
• Management of endometriosis-related pain (hormonal IUD use)
• Postpartum or interval IUD placement

When Not to Use CPT 58300

Do not use CPT 58300 in the following cases:

• When the IUD is removed, use CPT 58301 (Removal of IUD) instead.
• When removal and reinsertion occur in the same encounter, report CPT 58300 and 58301, appending modifier 51 (if required by payer).
• Do not report this code if the insertion attempt fails and the IUD is not placed - instead, report an appropriate E/M service for the encounter.

Coding and Billing Instructions For CPT 58300

• CPT 58300 covers only the insertion procedure.
• The IUD device itself is billed separately using the appropriate HCPCS Level II code, for example:
  • J7300 – Intrauterine copper contraceptive (Paragard®)
  • J7301 – Levonorgestrel-releasing IUD, 13.5 mg (Skyla®)
  • J7302 – Levonorgestrel-releasing IUD, 52 mg (Mirena®, Liletta®)
  • J7303 – Levonorgestrel-releasing IUD, 19.5 mg (Kyleena®)

Global Period and Separate E/M Billing

CPT 58300 has no global surgical period, meaning providers may bill a separately identifiable E/M service on the same day if evaluation and decision-making for IUD placement occur during the same visit. Append modifier 25 to the E/M code when documentation supports a significant, separately identifiable service.

Site of Service and Payer Authorization

This procedure is commonly performed in an office setting. Some payers require prior authorization for the IUD device (especially commercial carriers), while the insertion code itself generally does not require pre-approval. Always verify payer-specific contraceptive coverage policies.

Reimbursement Information

According to the current Medicare Physician Fee Schedule, the average reimbursement for CPT 58300 is approximately $75–$95 for the procedure alone (excluding the device). Commercial payers typically reimburse at slightly higher rates depending on contract terms.

Device Cost and Patient Coverage

IUD device reimbursement varies widely by product and payer, ranging from $700 to $900 for hormonal IUDs and $800 to $1,000 for non-hormonal copper IUDs. Under the Affordable Care Act, most insurance plans must cover FDA-approved contraceptive methods, including IUDs, without patient cost-sharing - though exceptions may apply.

Common Modifiers Used with CPT 58300

Proper modifier use clarifies the services performed and ensures accurate payment:

• Modifier 25 – Used with an E/M code when a significant, separately identifiable evaluation is performed during the same visit as the IUD insertion.
• Modifier 51 – When both removal (58301) and insertion (58300) are performed during the same session.
• Modifier 59 – Used if another unrelated procedure (e.g., biopsy, endometrial sampling) is performed in the same encounter.
• Modifier 76 – For repeat insertion by the same physician on the same day (rare).

Essential Documentation Elements

Thorough documentation ensures compliance, prevents denials, and supports both procedure and device billing. Records should include:

• Indication for IUD insertion (contraceptive or therapeutic)
• Type and brand of IUD inserted (with lot number)
• Counseling and informed consent documentation
• Description of the procedure, including cervical prep, uterine sounding, and insertion technique
• Confirmation of correct placement (string visibility, patient tolerance)
• Any complications or unsuccessful attempts
• Billing of device separately with HCPCS code

Importance of Accurate Documentation

Inadequate documentation is one of the leading causes of IUD-related claim denials. Clearly identifying the medical necessity, device used, and procedural steps not only ensures correct coding but also protects against audit risks.

Example Scenarios

Scenario 1 – IUD Insertion for Contraception

A patient presents for contraceptive counseling and elects Mirena® insertion after discussion. The provider performs the insertion procedure. → Bill CPT 58300 for insertion and J7302 for the device.

Scenario 2 – IUD Removal and Reinsertion

A patient requests removal of an expired Paragard® IUD and placement of a new Liletta® IUD during the same visit. → Report 58301 (removal) and 58300 (insertion) with modifier 51, and J7302 for the device.

Scenario 3 – Failed Insertion Attempt

A patient presents for IUD insertion, but due to cervical stenosis, the device cannot be placed. The provider performs only an examination and counseling. → Do not bill 58300; instead, report an E/M code with documentation of medical necessity.

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