CPT® Code 58301 is used to report the removal of an intrauterine device (IUD), a common form of long-acting reversible contraception. This procedure involves carefully extracting the IUD from the uterine cavity and is performed in-office, often during a routine gynecologic visit.
This code represents the procedure itself, including all steps necessary for safe removal. It does not include insertion, replacement, or related evaluation and management services, which should be billed separately if provided.
Key Facts About CPT® 58301
- Service type: Gynecologic procedure
- Provider type: Physicians, advanced practice providers, or qualified healthcare professionals
- Medical services included: Yes—complete removal of IUD from the uterine cavity
- Procedure setting: Office or outpatient clinic
- Common clinical indications:
- Planned removal after contraceptive use period
- Removal due to patient preference or side effects
- Management of IUD-related complications (e.g., pain, malposition)
- Transition to a different contraceptive method
When to Use CPT® 58301
CPT 58301 is appropriate when:
- The patient requires removal of an IUD for medical or personal reasons
- Removal is performed as a standalone procedure or as part of a routine contraceptive visit
- The provider directly extracts the IUD from the uterine cavity
- The service does not include IUD replacement (use CPT 58300 for removal with immediate reinsertion)
Examples:
- Routine removal of a copper or hormonal IUD after approved duration of use
- Removing an IUD due to irregular bleeding or discomfort
- Extracting an IUD prior to pregnancy planning or gynecologic procedure
Documentation Requirements
To support CPT 58301 billing, documentation should include:
- Patient identifiers and date of service
- Clinical indication for IUD removal
- Type of IUD removed (copper or hormonal)
- Technique used for removal and any complications
- Counseling or follow-up plans
- Provider credentials and signature
Accurate documentation ensures compliance, supports reimbursement, and promotes patient safety.
Reimbursement and Coding Considerations
- CPT 58301 is generally covered by commercial insurers and Medicare when medically necessary
- Billing should reflect IUD removal only; insertion or replacement requires separate CPT codes
- Office or outpatient facility fees may apply in addition to the procedure code
- Modifier use may be required if multiple procedures are performed on the same day
- Payer policies may specify coverage frequency for routine IUD removal
How OptiMantra Supports IUD Removal
OptiMantra’s integrated EMR and practice management system streamlines documentation and billing for CPT 58301:
With OptiMantra, providers can:
- Record IUD type, removal procedure details, and patient response in the chart
- Document counseling, follow-up, and contraceptive planning
- Generate compliant, audit-ready procedure billing codes
- Track longitudinal IUD history for individual patients
- Ensure seamless coordination of reproductive health care
By centralizing gynecologic procedure workflows, OptiMantra helps practices improve efficiency, ensure compliance, and optimize reimbursement.
Try OptiMantra for free here!
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