LARC: BEYOND THE BASICSMoira K. Ray, MD MPH

Valerie J. King, MD MPH

OAFP Spring Conference

April 13, 2018

OVERVIEW

Resources

Contraception Counseling

Intrauterine Contraceptives / Devices

Implant

Best Practices

Coding Tips

RESOURCES

American College of Obstetricians and Gynecologists: LARC Program Free LARC practice bulletins, clinical education, patient info

https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception

U.S. Selected Practice Recommendations for Contraceptive Use (2016) https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summar

y.html

U.S. Medical Eligibility Criteria (MEC) App In your friendly iPhone or Android app store

CONTRACEPTION COUNSELING

• Assess for unmet

contraception needs

One Key Question

• Experience

• Efficacy

• Interest

• Coverage

• Have resources on

hand

Reproductive Health Access Project:https://www.reproductiveaccess.org/

Bedsider.org

INTRAUTERINE DEVICES

TYPES OF IUDS

Device Levonorgestral

Dose (mcg/d)

FDA Approved

Duration

(years)

Evidence

Supported

Duration

Paragard N/A- Copper

based

10 12

Mirena 20 5 7-15

Skyla 14 3

Liletta 18.6 4* 5

Kyleena 17.5 5

Sources:

Bahamondes L, et al. (2018); Rowe, P, et al., (2016); Creinin et al., (2016); UN Development Program (1997)

*Manufacturer recently received FDA for extended duration approval

ELIGIBILITY & SAFETY

Adverse outcomes rare

Safe for adolescents, nulliparous women, postabortion, postpartum, breastfeeding

CDC Medical Eligibility Criteria Few contraindications for IUDs

CDC MEC: https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html

ACOG LARC: https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/LARC-Clinical-Resources

SAFETY CONTINUED..

Source: Contraceptive Technology and Reproductive Health Series

https://www.fhi360.org/sites/default/files/webpages/Modules/IUD/s1pg18.htm

SAFETY CONTINUED..

Slightly higher expulsion rate younger women (Cu-IUD), postpartum and post-abortion

But still has great cost and clinical effectiveness

Postpartum visit, if breastfeeding, is high risk time for perforation

Sources: Jatlaoui, Riley, Curtis (2017); Heinemann et al. (2015)

ANTICIPATORY COUNSELING

Your patient has likely reviewed multiple online news reports and blogs on IUD insertion and talked to all of her friends and social medial contacts . . .

CONSENT FOR PROCEDURE AND ANTICIPATORY COUNSELING

Understand what worries or scares her

What to expect from procedure

What to expect from having this device RHAP handouts/ after visit summary

3 months of patience

ASSESS FOR CURRENT PREGNANCY RISK

Source: https://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/248124_box1_app_b_d_final_tag508.pdf

1. BMI is not needed to determine eligibility, may be helpful for monitoring with women concerned for weight gain.

2. “Most women do not require additional STD screening at the time of IUD insertion…screen… according to CDC’s STD Treatment

Guidelines”

Source: https://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/248124_box1_app_b_d_final_tag508.pdf

IUD INSERTION TIPS

Know uterine anatomy

Use tenaculum Align axis of cervix and uterus

Adjust uterine position

Control point for sounding, insertion

Proprioception

Posterior lip for retroverted uterus

Source: Rowland, Oloto, Horwell (2015)

IUD INSERTION TIPS

Tenaculum slow closure vs fast closure

2 RCTS found less patient reported pain for slow (7-10 sec)

Shallow sounding 6 cm or less counseling for expulsion

< 5 cm consider US to eval if need to straighten uterus, suspect still in cervix

Deep sounding >9cm STOP, perforation risk

Consider repeat procedure in 2 weeks or more with use of ultrasound guidance vs. ref to more experienced clinician

IUD INSERTION PAIN MANAGEMENT

Evidence does not support routine misoprostol use Misoprostol may increase patient pain and GI effects

Unsuccessful first attempt? Consider 400mcg misoprostol (buccal) 4 hours before

Consider topical lidocaine (2%) or paracervical block (1-2%)

Pre-procedure anxiolytic

Nitrous?

No evidence on improvement of pain with NSAIDs, but not likely harmful either

U.S. SPR (2016); Lopez et al. Cochrane Database Sys Rev 2015; Zapata et al. Contraception

2016; ACOG (2017) Clinical Challenges of LARC

IUD REMOVAL TIPS Missing strings?Cytobrush

String retriever

US to confirm intrauterine location

Intrauterine approaches (e.g. MVA, alligators) or referral

Hook is useless

Comfi Device

ISSUES WITH AN IUD IN PLACE

Source: https://www.healthline.com/health/birth-control/iud-side-effects

HEAVY BLEEDING

In a progestin IUD userConsider ultrasound to eval for low-lying device

In a copper IUD user Reassurance in first 3-6 months, may decrease

NSAIDs for 5-7 days

Consider tranexamic acid (Lysteda)

U.S. SPR has algorithms for bleeding issues

Source: U.S. SPR (2016) https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html

Kost & Pitney (2011) American Family Physician

LOW-LYING IUDS

Common incidental finding

Copper IUD associated with increased odds of pregnancy, but unclear

ACOG supports shared decision making and leaving IUD in place, if asymptomatic Replace low-lying IUD if pelvic pain, bleeding

Provide another effective contraceptive agent

Low-lying ≠ Intracervical Intracervical is partially expulsed, needs replacement

Source: ACOG (2017) Clinical Challenges of LARC

STDS

Not all women need STD screening at time of insertion

Follow national CT/GC testing recommendations

25 years and under, if sexually active

> 25 years if new partner, multiple partners, or partner with an STD

If screening identifies GC/CT infection, okay to treat with IUD

CDC and ACOG support treating through PID as well

If no improvement in 48-72 hours, then remove, provide alternative effective contraception, and treat

U.S. SPR has algorithms for PID management with IUD in place

Source: U.S. SPR (2016) https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html

MORE MYTHS

Nulliparous women can’t handle insertion

Insertions are painless in multiparous women

Actinomyces necessitates removal

Only women have IUDs

Return visit for string check

ALSO

Mirena is indicated for menorrhagia

Levonorgesterol as part of HRT

Paragard for emergency contraceptionWithin 5 days of unprotected intercourse

CONTRACEPTIVE IMPLANT

TYPES OF IMPLANT

Nexplanon(etonogestrel) Replaced Implanon, and now radio-opaque

FDA approved for 3 years, evidence for 5

Works if BMI >30

Sources: https://www.self.com/story/nexplanon-implant-birth-control

Ali et al., (2016); U.S. SPR (2016); U.S. MEC (2016).

EFFICACY OF IMPLANT

Implant is most effective Greater than permanent surgical options

Source: https://www.cdc.gov/media/releases/2015/p0407-teen-pregnancy.html

ELIGIBILITY

Appropriate options for vast majority of women, including teens

Situations where risk exceed benefits are rare E.g. malignancies, cirrhosis, unexplained vaginal bleeding

Same day insertions Reasonably certain not pregnant

Safe in breastfeeding, including immediate postpartum

Source: CDC Medical Eligibility Criteria

ANTICIPATORY COUNSELING

Assess for anxiety habits (picking)

BleedingUnpredictable who will have none, some, or “too much”

Breast tenderness

Nausea

Source: U.S. SPR (2016); ACOG (2017) Clinical Challenges of LARC;

INSERTION TIPS

Avoid deep insertions Subdermal location (not intramuscular)

No touch technique (do not need sterile gloves)

Easiest LARC for same day insertions

Source: https://obgynkey.com/contraception-12/

ISSUES ARISING WITH IMPLANT

Bleeding Trial of 5-7 days of NSAIDs

Trial of 10-20 days of OCPs

Unpalpable deviceWeight gain?

US or XR to confirm location

Desire for an alternative location Scapula?

Source: U.S. SPR (2016); ACOG (2017) Clinical Challenges of LARC; Pragout et al. (2018)

IMPLANT REMOVAL TIPS

Push distal tip to surface

Numb entire track if replacing

Counsel on quick return to fertility

Source: http://www.arhp.org/publications-and-resources/clinical-proceedings/Single-Rod/History

REMOVAL TIPS

Pop out technique https://vimeo.com/145221377

Lidocaine under the distal end to lift up tip

Unable to isolate the distal end? Pinch in the middle and grab with vasectomy forceps, if available

CODING TIPS

CODING FOR LARCWhat you did (CPT) Device Used (HCPCS) Why / Description

(ICD-10)

58300

(IUD insertion)

58301

(IUD removal)

No code for swap-

out

J7297 levonorgestrel 52, 3

year

J7298 levonorgestrel 52, 5

year

J7300 Copper IUD

J7301 Leveonoregestrel

13.5mg

Z30.430 Encounter for IUD

insertion

Z30.432 Encounter for IUD

removal

Z30.433 Encounter for removal

and reinsertion IUD

Z97.5 presence of IUD

1191 insertion

implant

11982 removal

implant

11983, swap out

J7307 etonogestrel implant V25.5 insertion of subdermal

implant

V30.49 checking, reinsertion or

removal of implant

Source: http://larcprogram.ucsf.edu/coding

BEST PRACTICES

Efficacy based counseling

Same day insertions IUD/implant insertion “bundles” of supplies to have close by in clinic

Immediate postpartum insertions

Systems approach train others, anticipate triage calls to nursing

Cardea training on Postpartum IUD insertion (CME) from Univ. of Washington Faculty

http://www.cardeaservices.org/resourcecenter/inserting-long-acting-reversible-contraception-larc-immediately-after-childbirth

THANK YOUQUESTIONS?

ADDITIONAL TECH RESOURCES

CDC MEC/SPR app available in apple app store

Contraception Point-of-Care (Family Doc Josh Steinberg)

CODING FOR LARCWhat you did (CPT) Device Used (HCPCS) Why / Description

(ICD-10)

58300

(IUD insertion)

58301

(IUD removal)

No code for swap-

out

J7297 levonorgestrel 52, 3

year

J7298 levonorgestrel 52, 5

year

J7300 Copper IUD

J7301 Leveonoregestrel

13.5mg

Z30.430 Encounter for IUD

insertion

Z30.432 Encounter for IUD

removal

Z30.433 Encounter for removal

and reinsertion IUD

Z97.5 presence of IUD

1191 insertion

implant

11982 removal

implant

11983, swap out

J7307 etonogestrel implant V25.5 insertion of subdermal

implant

V30.49 checking, reinsertion or

removal of implant

Source: http://larcprogram.ucsf.edu/coding

FOLLOW-UP QUESTIONS?

Moira K. Ray, MD, MPH

raymo@ohsu.edu

Valerie J. King, MD, MPH

kingv@ohsu.edu

AAFP Reproductive Health Interest Group:

https://www.aafp.org/membership/involve/mig/reproductive-health-care.html