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2025 HCPCS code S4981

Insertion of a levonorgestrel-releasing intrauterine system.

This code is obsolete; use J7302 instead.Refer to payer-specific guidelines for billing practices.

The medical necessity for IUD insertion is established by the patient's informed choice for contraception or management of specific gynecologic conditions (e.g., heavy menstrual bleeding).Appropriate counseling should document the patient’s understanding of risks, benefits, and alternatives.

Obstetrician-Gynecologist or qualified healthcare professional trained in IUD insertion.

IMPORTANT:Replaced by J7302 (Levonorgestrel-releasing intrauterine contraceptive system, 52 mg) as of October 1, 2005.

In simple words: This code covers placing a small device inside the uterus to prevent pregnancy. This device slowly releases hormones to stop pregnancy for several years.

This HCPCS code represents the insertion of a levonorgestrel-releasing intrauterine device (IUD) for contraception.The procedure involves a bimanual exam, speculum insertion, cervical manipulation, potential anesthesia administration (especially if dilation is necessary), assessment of uterine depth and structure, device preparation, insertion, positioning, release, and instrument removal. The IUD gradually releases the hormone levonorgestrel to prevent pregnancy for 3-5 years.

Example 1: A 28-year-old woman desires long-term contraception and chooses a levonorgestrel-releasing IUD. The physician performs the insertion procedure, including a bimanual exam, speculum insertion, and careful placement of the device., A 35-year-old woman presents for IUD insertion after childbirth.Due to postpartum changes, the physician administers local anesthesia to facilitate the procedure and ensures appropriate uterine positioning before device placement. , A 25-year-old patient experiences heavy menstrual bleeding and chooses an IUD for both contraception and management of menorrhagia. The provider explains the procedure and addresses potential side effects before inserting the device.

Patient history (including reproductive history, allergies, current medications), informed consent, physical examination notes (including bimanual exam findings), procedure notes detailing the insertion technique, and any complications encountered during the procedure.

** While this code is obsolete, understanding its historical context is crucial for accurate record-keeping and claims processing. Documentation of the device used should be clearly stated, along with the date of the procedure and any relevant complications.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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