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Editorial


Let’s increase our use of implants and DMPA and improve contraceptive effectiveness in this country

We do not use long-acting reversible contraceptives in the United States at the rate they are used in Europe, and we have a high unplanned pregnancy rate to show for it. Expanding the patient population to which we prescribe implants and depot medroxyprogesterone acetate could help us in our mission to decrease the number of unplanned pregnancies.

September 2012 · Vol. 24, No. 9

READ THE FIRST OF 2 PARTS

Let’s increase our use of IUDs and improve contraceptive effectiveness in this country
Robert L. Barbieri, MD (Editorial, August 2012)

In the United States, approximately 49% of pregnancies are reported to be unplanned. From 1995 to 2008 the rate of unintended pregnancy decreased by 42% in Europe, but did not decrease at all in North America.1 One factor contributing to the difference: in Europe, long-acting reversible contraceptives (LARCs) are more widely used than in North America. In the United States, increasing the use of LARCs would cause a decrease in the unplanned pregnancy rate.

Tip for placing the etonogestrel implant (Hint, sit down!)

In this 2-part editorial, I am focusing on the expanding clinical indications of LARCs, including:

  • copper intrauterine device (IUD)
  • levonorgestrel-releasing intrauterine system (LNG-IUS)
  • etonogestrel-releasing implant (Implanon, which is being transitioned to Nexplanon [see “Completing the Nexplanon training process” on page 10])
  • depot medroxyprogesterone acetate (DMPA) injection, which is also a highly effective contraceptive method.

“In last month’s editorial, I focused on the copper IUD and the LNG-IUS.” Here, I am focusing on the etonogestrel-releasing implant and DMPA.


In practice, I observe most clinicians placing the etonogestrel implant from a standing position. One complication of insertion is placing the implant too deeply in the arm (for example, placing the implant in the biceps muscle). You can reduce the potential for this complication by sitting down and directly observing implant placement from the side of the patient’s upper arm, rather by standing above her arm.

The implant and obesity: Effectiveness not defined, but not shown to be ineffective

CASE 2

A 65-in, 250-lb (body mass index, 41.7 kg/m2) woman asks if she can have an etonogestrel implant.

Would you place an etonogestrel implant in this obese woman?

Argument for etonogestrel implant use in obesity. The FDA-approved package insert for the etonogestrel implant states, “The effectiveness of the etonogestrel implant in women who weighed more than 130% of their ideal body weight has not been defined because such women were not studied in clinical trials. Serum concentrations of etonogestrel are inversely related to body weight and decrease with time after implant insertion. It is therefore possible that Nexplanon may be less effective in overweight women, especially in the presence of other factors that decrease serum etonogestrel concentrations such as concomitant use of hepatic enzyme inhibitors.”6 Drugs that induce cytochrome P450 3A4 (CYP3A4) increase the metabolic clearance of etonogestrel. CYP3A4 inducers include barbiturates, phenytoin, topiramate, carbamazepine, and St. John’s wort.

In a large, prospective observational study of 1,168 women who received the etonogestrel implant, only one pregnancy occurred over 1,377 woman-years.7 The pregnancy occurred in a woman with a BMI of 30.7 kg/m2. In this study, the contraceptive failure rate was not significantly different between normal, overweight, and obese women. The cumulative contraceptive failure rate among the obese women was 0.23 per 100 woman-years. By contrast, the contraceptive failure rate among 1,527 women using a contraceptive pill, patch, or vaginal ring was 4.55 per 100 woman-years.8 Based on results from these and other studies, I feel comfortable providing etonogestrel implants to overweight and obese women.

Completing the Nexplanon training process

The Implanon device is being transitioned to the Nexplanon device. Nexplanon has an improved insertion system, with a safety needle. Unlike Implanon, Nexplanon can be imaged by standard x-ray because it has barium impregnated in the device.

For providers who have previously completed training for the Implanon device, training for the Nexplanon device can be completed online. You can sign up for the Web-based or the in-person clinical training program through Merck’s Web portal for Nexplanon (www.nexplanon-usa.com/en/hcp/services-and-support/request-training/request-form/index.asp).

DMPA is safe immediately postpartum

CASE 3

A 23-year-old G1P1 woman is planning on exclusively breastfeeding her newborn daughter. She has used DMPA successfully in the past and she asks you to prescribe an injection before her hospital discharge.

Would you prescribe DMPA injections to this breastfeeding woman?

Argument for DMPA use immediately postpartum. The FDA-approved product information for DMPA recommends initiating injections 4 to 6 weeks postpartum regardless of the mother’s breastfeeding status. The World Health Organization recommends that DMPA not be initiated prior to 6 weeks postpartum in breastfeeding women. The available research suggests, however, that DMPA is safe to administer immediately postpartum because:9

  • DMPA has no significant effect on the development of breastfed infants
  • DMPA has a low risk of maternal complications.

The bottom line. Considering the high rate of unintended pregnancy, it is reasonable to prescribe the woman in case 3 an immediate postpartum DMPA injection and schedule her for appropriate postpartum follow-up.

Coding for contraceptive implants and DMPA

In the August 2012 issue of OBG Management, I discussed coding and billing for an intrauterine device (IUD). See “Reimbursement for your IUD insertion, and reinsertion, work”, on page 45 of “Malpositioned IUDs: When you should intervene (and when you should not).” This month, I continue with coding for other types of long-acting reversible contraceptive methods, namely the under-the-skin contraceptive implant system and contraceptive-strength injections of depot medroxyprogesterone (DMPA).

Etonogestrel-releasing implant

Changes to Current Procedural Terminology (CPT) which were effective January 1, 2012, had an impact on coding for the etonogestrel-releasing implant (Nexplanon). Prior to that date, most payers required the contraceptive insertion code 11975 (Insertion, implantable contraceptive capsules). After this date, and with the deletion of CPT code 11975, the insertion is reported with:

  • 11981 (Insertion, non-biodegradable drug delivery implant)
  • linked to the diagnosis code V25.5 (Insertion of implantable subdermal contraceptive).

A caveat. You should be aware, however, that if a patient comes in for removal of Norplant capsules and has a Nexplanon rod inserted at the same encounter, CPT instructions are to report 11976 and 11981. That means you will submit a claim with 11976 linked to diagnosis code V25.43 (Surveillance of previously prescribed contraceptive methods; implantable subdermal contraceptive) and 11981-51 (Insertion, non-biodegradable drug delivery implant; multiple procedures) linked to diagnosis code V25.5. As with all multiple procedures, the highest valued code is always listed first to maximize reimbursement.

In-office insertion. When the insertion is performed in the office setting, the relative value is higher due to the increased practice expense and includes the drug supply (J7307, Etonogestrel (contraceptive) implant system, including implant and supplies). Unless your payer is not reimbursing using relative value units, you should not be coding the implant system separately. Be sure to check payer guidelines to avoid payment delays and possible denials for this supply.

DMPA

When a patient selects an injectable contraceptive instead of the subdermal implant, coding becomes more straightforward. The injection procedure is reported using:

  • 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular)
  • J1055 (Injection, medroxyprogesterone acetate for contraceptive use, 150 mg).

Note that CPT rules do not allow reporting code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services) with the injection code. If a separate significant E/M service is provided at the time of the visit (meaning 99201-99205 for new patient visits, or 99212-99215 for established patient visits), a modifier -25 must be added to the E/M service or the injection procedure will be denied as bundled. The injection code also requires direct physician supervision. If the billing provider is not in the office at the time of the injection and an RN administers the injection, code 99211 is billed instead of 96372. Keep in mind, however, that this might mean that some payers will deny the injection procedure under “incident to” rules for ancillary services.

—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.

“Lead, follow, or get out of the way”

In the pivotal year of 1776, Thomas Paine coined the phrase, “Lead, follow, or get out of the way.”10 Among medical specialists, only we ObGyns have the training and passion to lead the charge to wider use of LARCs.

HAVE YOU READ THESE 2012 ARTICLES ON CONTRACEPTION?

Click here to find additional articles on contraception published in OBG Management in 2012.

References

1. Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels trends, and outcomes. Stud Fam Plann. 2010;41(4):241-250.

2. Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol. 2012;206(6):481.e1-e7.

3. Reinprayoon D, Taneepanichskul S, Bunyavejchevin S, et al. Effects of etonogestrel-releasing contraceptive implant (Implanon) on parameters of breastfeeding compared to those of an intrauterine device. Contraception. 2000;62(5):239-246.

4. World Health Organization Task Force for Epidemiological Research on Reproductive Health; Special Programme of Research, Development and Research Training in Human Reproduction. Progestogen-only contraceptives during lactation: I. Infant growth. Contraception. 1994;50(1):35-53.

5. Brito MB, Ferriani RA, Quintana SM, Yazlle ME, Silva de Sá MF, Viera CS. Safety of etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception. 2009;80(6):519-526.

6. Nexplanon [package insert]. Whitehouse Station NJ: Merck & Co, Inc.; 2012.

7. Xu H, Wade JA, Peipert JF, Zhao Q, Madden T, Secura GM. Contraceptive failure rates of etonogestrel subdermal implants in overweight and obese women. Obstet Gynecol. 2012;120(6):21-26.

8. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998-2007.

9. Rodriguez MI, Kaunitz AM. An evidence-based approach to postpartum use of depot medroxyprogesterone acetate in breastfeeding women. Contraception. 2009;80(1):4-6.

10. Paine T. The American Crisis. No. 1. December 19 1776.

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