A gynecologist’s job is not just to deliver babies but also to counsel patients on several contraceptive methods available out there. Each of these drugs has its unique benefits and associated risks. Thus, patients must be fully educated before they make the final call. Yes, it does add to the complexity of the overall care plan. The same is true when it comes to OBGYN billing for implant insertion procedures, such as the one covered by CPT code 11981.
We decided to share our knowledge of medical billing through this guide. It discusses the clinical scenarios, applicable modifiers, and reimbursement guidelines to help you master CPT 11981 billing.
So, without further ado, let’s get started!
CPT Code 11981 – Description
CPT code 11981 covers the insertion of an implant for long-term delivery of a drug. It could be a pellet or capsule containing the medicine. Besides, the implant can be biodegradable, bioresorbable, or non-biodegradable.
Scenarios Where CPT Code 11981 is Applicable
Do you want to understand how CPT 11981 applies to real-world clinical scenarios? If yes, continue reading:
Hormonal Contraceptive Implant
Picture a 26-year-old female patient who visits the OBGYN clinic. She requests a reliable, long-acting form of birth control. With the help of her gynecologist, she chooses a progestin-containing rod-shaped implant. This device is capable of delivering hormonal contraception for up to three years.
The procedure during which the gynecologist inserts the implant will be billed using CPT code 11981.
Testosterone Pellet Therapy
Assume a 55-year-old male patient with confirmed hypogonadism. It is a condition with low testosterone and requires sustained testosterone replacement therapy. Thus, after counseling with the physician, he opts for the testosterone pellets that will be inserted subcutaneously every three to six months.
For the insertion, the physician makes a small incision under sterile conditions and local anesthesia. He then implants multiple bioresorbable testosterone pellets using a specialized trocar into the fat layer beneath the skin.
Here, CPT code 11981 applies.
Estradiol Pellet Insertion for Menopausal Therapy
Imagine a 52-year-old female patient in her post-menopausal phase. She has been experiencing severe hot flashes, night sweats, and fatigue. Thus, the gynecologist counseled her and decided on sustained-release estradiol hormone pellets for customized hormone replacement therapy (HRT).
Thus, after prepping a sterile site and administering anesthesia, a small incision is made. The gynecologist then implants two to three bioresorbable estradiol pellets into the subcutaneous fat layer using a trocar.
Here, CPT code 11981 may be reported to bill for the procedure.
Applicable Modifiers for CPT Code 11981
The following are some of the applicable modifiers for CPT 11981:
Modifier 51
What happens when the physician performs another procedure during the same surgical session as the CPT code 11981? You report the service with modifier 51. The payer will reimburse the primary higher value procedure at a 100% rate and the secondary service at a 50% rate.
Modifier FP
If you performed the implant insertion as part of a family planning service, do not forget to append modifier FP to CPT code 11981.
CPT Code 11981 – Billing & Reimbursement Guidelines
Discussed below are the essential billing and reimbursement requirements for implant insertion:
Ensure Detailed Documentation
Comprehensive and accurate documentation is key to demonstrating the medical necessity of the rendered service. Besides, it is one of the billing requirements that is encouraged by all payers. Thus, your documentation for CPT code 11981 must include:
- Details related to the pre-procedure counseling in which the physician clearly states the benefits, alternatives, and risks associated with the implant. Additionally, the healthcare provider must obtain patient consent.
- Procedure notes should include details related to the site of insertion, e.g., right gluteal fat pad, the type and amount of administered anesthesia, insertion technique, and closure method.
- Mention the implant details, including drug name, dosage, and lot number.
Do Not Report CPT Code 11981 and 11982 Together
Did the physician remove a previously implanted capsule or pellet and then insert a new one? In such scenarios, the biggest blunder one can make is by reporting CPT codes 11982 (implant removal) and 11981 (implant insertion) together.
The reason is simple! There is another, more specific code available, i.e., CPT 11983. It covers both the removal of the old implant and the insertion of a new implant.
Understand the Payer-Specific Guidelines
While some private payers follow the guidelines set forth by the Centers for Medicare and Medicaid (CMS), most commercial payers have the autonomy to come up with their own rules.
Thus, try to communicate with the relevant payer, understand specific policies, and adhere to the specific guidelines to prevent denials against CPT code 11981.
Summary
With that said, it is time to conclude this guide. But before we say adieu, let’s quickly recap the key pointers.
The CPT code 11981 descriptor covers the bioresorbable, biodegradable, or non-biodegradable implant insertion.
Additionally, we shared a few real-world clinical scenarios to help you better understand where this procedural code applies. These include estradiol pellet insertion for menopausal therapy, testosterone pellet therapy, and hormonal contraceptive implant.
Since coding specificity often depends upon appropriate modifier usage, we also ensured to include the key modifiers 51 and FP.
Finally, we discussed the documentation requirements, specific payer policies, and why you should not bill CPT 11981 and 11982 together.
Hopefully, this guide will become your go-to resource for billing implant insertion procedures. However, if you still struggle, feel free to outsource OBGYN billing services to MediBillMD.
