HCPCS Level II S4981: Insertion of Levonorgestrel-Releasing Intrauterine System - OpenPayer

Summary & Overview

HCPCS Level II S4981: Insertion of Levonorgestrel-Releasing Intrauterine System

HCPCS Level II code S4981 designates the insertion of a levonorgestrel-releasing intrauterine system, a common long-acting reversible contraceptive option. Nationally, this code matters for tracking utilization of long-acting contraception, billing for device placement services, and understanding outpatient gynecologic procedural care patterns. The procedure typically occurs in outpatient clinics, ambulatory surgery centers, or physician offices and involves placement of a hormone-releasing intrauterine device.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how S4981 is used in clinical billing, benchmark measures for service lines, and the clinical context surrounding levonorgestrel-releasing intrauterine system placement. The publication summarizes common billing practices, expected sites of service, and the role of this procedure in contraceptive care delivery. It also highlights areas where readers may need to consult payer-specific policies or local coding guidelines.

Data not available in the input for payer-specific rates, claim benchmarks, associated taxonomies, and ICD-10 diagnosis pairings.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareS4981HCPCS Level IIintrauterine systemlevonorgestrelcontraceptive insertionoutpatient proceduregynecologyLARC

Billing Code Overview

HCPCS Level II code S4981 describes the insertion of a levonorgestrel-releasing intrauterine system. This service involves placement of a long-acting, hormone-releasing intrauterine contraceptive device containing levonorgestrel.

Service type: Contraceptive device insertion procedure
Typical site of service: Outpatient clinic, ambulatory surgery center, or physician office where gynecologic procedures are performed

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 29-year-old nulliparous female presents to a gynecology clinic seeking long-acting reversible contraception. She desires effective contraception for several years and requests placement of a levonorgestrel-releasing intrauterine system. Pre-procedure evaluation includes pregnancy test, review of medical history, and screening for active pelvic infection. Procedure is scheduled in an outpatient ambulatory surgery center or office-based procedure room equipped for minor gynecologic procedures. On the day of service the patient is placed in lithotomy position, a sterile speculum exam is performed, the cervix is cleansed, and a tenaculum may be used for traction. The uterine sounding confirms uterine depth and orientation. The levonorgestrel-releasing intrauterine system is loaded into the inserter and released into the uterine cavity per manufacturer technique. Post-insertion counseling covers string checks, expected bleeding pattern changes, and signs of infection. A brief observation period follows; documentation includes informed consent, device lot and serial number, implant insertion note, and follow-up plan. Typical site of service: outpatient ambulatory surgery center or office-based procedure room. Service type: intrauterine device insertion procedure corresponding to insertion of a levonorgestrel-releasing intrauterine system billed with S4981.

Coding Specifications

Modifier	Description	When to Use
`00`	Default/unspecified

HCPCS Level II S8425: Gradient Pressure Glove, Custom, Medium Weight

HCPCS-S8037-MRCP-MAGNETIC-RESONANCE-CHOLANGIOPANCREATOGRAPHY

HCPCS S8037: Magnetic Resonance Cholangiopancreatography

HCPCS-S0630-SUTURE-REMOVAL-BY-DIFFERENT-PHYSICIAN

HCPCS Level II S0630: Removal of Sutures by a Different Physician

HCPCS-S8430-PADDING-COMPRESSION-BANDAGE-ROLL

HCPCS S8430: Padding for Compression Bandage, Roll

HCPCS-S9117-BACK-SCHOOL-PER-VISIT

HCPCS S9117: Back School, Per Visit

HCPCS-S8100-INHALER-SPACER-HOLDING-CHAMBER-NO-MASK

HCPCS S8100: Holding Chamber/Spacer for Inhaler or Nebulizer, No Mask

HCPCS-S8030-SCLERAL-TANTALUM-RING-LOCALIZATION-PROTON-THERAPY

HCPCS S8030: Scleral Tantalum Ring Localization for Proton Therapy

HCPCS-S3855-PRESENILIN-1-GENETIC-TESTING

HCPCS S3855: Genetic Testing for Presenilin-1 Mutations

HCPCS-S2209-MINIMALLY-INVASIVE-CORONARY-BYPASS-TWO-ARTERIAL-ONE-VENOUS-GRAFT

HCPCS S2209: Minimally Invasive Coronary Artery Bypass, 2 Arterial + 1 Venous

HCPCS-S9376-HOME-INFUSION-HYDRATION-2-TO-3-LITERS-PER-DAY

HCPCS S9376: Home Infusion Hydration Therapy, 2–3 Liters/Day

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Taxonomy Code	Specialty	Notes
`261QM0800X`	Obstetrics & Gynecology	Most common specialty performing IUD insertions in outpatient settings.
`261QA2200X`	Family Medicine	Many family medicine clinicians provide contraceptive IUD insertion in primary care clinics.
`207RH0000X`	Reproductive Endocrinology/Infertility	Performs insertions in complex reproductive patients or when combined with fertility procedures.
`263R00000X`	Nurse Practitioner	Nurse practitioners frequently perform counseling and IUD insertions in clinic settings.
`363L00000X`	Women's Health/Certified Nurse Midwife	Certified nurse midwives commonly insert levonorgestrel IUDs during gynecologic visits.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N92.0`	Excessive and frequent menstruation with regular cycle	Indication for levonorgestrel IUS to reduce menstrual bleeding.
`N92.4`	Excessive bleeding in the premenopausal period	Common reason to place LNG-IUS for bleeding control.
`N89.0`	Noninflammatory polyp of cervix uteri	May require evaluation or treatment prior to IUD insertion; relevant to pre-procedure management.
`Z30.430`	Encounter for insertion of intrauterine contraceptive device	Specific encounter code denoting IUD insertion service.
`Z30.09`	Encounter for other contraceptive management	Used when managing contraceptive needs including counseling and device services.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`58300`	Insertion of intrauterine device (IUD)	Direct procedural analog to `S4981`; often used by payers for surgical/professional IUD insertion coding when billing CPT is appropriate.
`57461`	Colposcopy of cervix including upper/adjacent vagina; diagnostic	May be performed prior to insertion if abnormal cervical findings require evaluation before device placement.
`57170`	Endometrial biopsy, without cervical dilation	May be performed before or at time of visit if abnormal uterine bleeding is evaluated in the same encounter.
`99213`	Office or other outpatient visit for established patient, moderate complexity	Typical evaluation and management visit preceding or following device insertion.
`99070`	Supplies and materials provided by the physician over and above those usually included with the office visit or procedure	Used to report additional disposable supplies or device-related items when payer allows; device itself billed separately as `S4981`.

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