LARC
Toolkit

About this Document Version of the Toolkit

This toolkit contains resources and information that may be revised as evidence is updated or new tools we created to respond to identified needs. This is the most current version of the entire toolkit and individual components. To download a copy of this website, click here.

Authors

Abigail L. Reese, PhD, CNM, Lisa Hofler, MD, MPH, MBA, and Eve Espey, MD, MPH

New Mexico Perinatal Collaborative

The New Mexico Perinatal Collaborative (NMPC) is a nonprofit, multi-disciplinary coalition of stakeholders that seeks to improve the health of New Mexico women and children through the identification and sharing of best practices with perinatal care providers and hospitals around the state.

To View Acknowledgements Please Click Here

Introduction

This toolkit is designed to help healthcare providers and hospitals to provide LARC methods during a hospitalization for childbirth. The NM Medicaid Program covering 72% of births in New Mexicoⁱⁱⁱ, issued policy guidance in 2013 allowing inpatient reimbursement for LARC devices (IUDs and implants) and insertion fees outside of the DRG payment for childbirth. All managed care organizations (MCOs) participating in Centennial Care were required to reimburse devices and insertion fees for LARC inserted during a post-delivery hospital stay. UNM Hospital took the lead by implementing system changes to stock devices on impatient units, train clinical staff, adjust automated billing processes, and update electronic medical record templates. Medicaid and the MCOs addressed inevitable glitches in the reimbursement process as they rose. Postpartum LARC proved to be popular among Medicaid-covered women delivering at UNMH. However, by 2016 it was clear that a concerted effort was needed to make postpartum LARC available at other NM hospitals, and the New Mexico Perinatal Collaborative (NMPC) designed this toolkit to support that effort.

What is LARC?

These methods provide the highest level of reversible protection against pregnancy. All are appropriate for women throughout the reproductive years, including adolescents, and all are appropriate for postpartum women who have received patient-centered counseling on risks and benefits. Up-to-date sources provide more detailed information on each option, including:

Bedsider.org

The United States Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC)

Why offer immediate postpartum LARC?

The U.S., rate of unintended pregnancy is 45%. New Mexico’s unintended pregnancy rate, last measured at 55% is among the highest in the country^iv. NM women face barriers to contraception access. The period immediately following birth is an excellent opportunity women who want to prevent or control the timing of a subsequent pregnancy. Forty to fifty-seven percent of women resume intercourse before a postpartum clinic visit, and many do not attend a postpartum visit at all.

70% of pregnancies within the first year postpartum are unintended. These short-interval pregnancies are an independent risk factor for preterm birth and adverse neonatal outcomes.

The American Congress of Obstetricians & Gynecologists (ACOG) recommends that hospitals and clinicians adopt strategies to promote access to immediate postpartum LARC. Committee Opinion #670^v

Reproductive Autonomy

Our ultimate objective is to eliminate barriers to LARC access so that IUDs and implants become a readily accessible contraceptive option. Contraceptive access promotes reproductive autonomy for all women. LARC is different from other contraception because it requires clinician encounters to both place and remove IUDs or implants. We encourage all clinicians and administrators to consider the power dynamics inherent in this situation, especially considering histories of reproductive coercion disproportionately affecting communities of color and other marginalized groups of women. The NMPC has endorsed the LARC Statement of Principles articulated by the National Women’s Health Network and SisterSong. We encourage all providers to review this document and consider how to fully integrate these principles into their own LARC programs.

LARC Statement of Principles

LARC Removal:

Hospitals and clinicians should consider the issue of LARC removal alongside the development of a LARC program. Clinicians who place the immediate postpartum LARC must also offer access to removal within their own practice. Important considerations include:

Counseling women on the right to determine the timing of LARC removal
Information about where removals are offered
Anticipated cost of removal

Satisfaction and continued use of a method is associated with the quality of contraceptive counseling received ^vi

How to use this toolkit

The implementation of a hospital-based LARC program requires collaboration among a range of departments and individuals who hold responsibility for different components of service delivery. Therefore, this toolkit is organized by roles as defined in the following Implementation Guide.

Clinicians (physicians, lactation consultants, midwives, and nurses)
Administrators/Finance Professionals
Pharmacists
Information Technology Professionals

Each role can identify and focus directly on the tools, resources, and guidance that is targeted to their own needs. Groups can explore how these components are framed for different roles and share resources with team members as needed. Some tools are relevant across roles, and some may be unique or useful primarily to a specific audience.

Remember that the most up-to-date electronic versions are available on this website.

Implementation Guide

The guide is intended to be flexible and adaptable based on local considerations. Hospitals may use this guide to anticipate and plan for each stage of implementation, but not every task will be necessary in every institution. This guide may also serve as a tool to assess progress at regular intervals. (PDF Version)

LARC Implementation: Step 1

Champion Role	Tasks (You Need One Overall Champion)
Clinician Pharmacy Finance	Identify champions: Project champions should include individuals in a variety of clinical and administrate roles. It is critical to identify Clinical Pharmacy Finance Leads Who will have a direct role in service provision and reimbursement.
Clinician	Promote clinical evidence: Clinical leads must be prepared to share the evidence base for immediate postpartum LARC including: Safety Clinical benefits The rationale for implementing a hospital program (see Provider Research & Resources section of Toolkit.)
Pharmacy Finance	Assure insurance participation: Educate team members that all Centennial Care MCOs and fee-for-service Medicaid reimburse for LARC outside of the DRG for childbirth.
Pharmacy Finance	Confirm device cost & reimbursement rates: If needed for budgeting and planning purposes, obtain device cost information from the manufactures. Check NM Medicaid Portal for the most up-to-date reimbursement rates: http://www.hsd.state.nm.us/providers/fee-schedules.aspx
Clinician Pharmacy	Confirm administrative buy-in: This will vary by hospital and leadership structure. Determine the need for administrative education, involvement, and on-going communication.
Clinician Pharmacy Finance IT/EHR	Assemble immediate postpartum LARC team / Plan for ongoing communication or meetings: Ideally, identified clinical pharmacy, and finance champions, along with IT representation, will continue on as the IPP LARC team with assigned areas of responsibility. A plan for regular meetings or communication is needed to promote progress amid completing work demands. Consider what may be the most efficient process for your institution, including dedicated time within established service-level team meetings, or separate workgroup meetings.

LARC Implementation: Step 2

Champion Role	Tasks (You Need One Overall Champion)
Clinician	Documents Training
Pharmacy	Confirm that devices are on formulary. If not, then work with clinicians to initiate application to Pharmacy & Therapeutics Committee (See toolkit Clinical Evidence folder for resources.) Determine how to obtain devices: from bulk medical supplier? From manufacturer? Are new contracts or updates required? Work with IT to add devices to inventory systems. Determine distribution plan that accounts for need for rapid accessibility. Work with clinicians to determine order volume and order devices.
Finance	Determine billing mechanism for LARC devices. Options include: Enroll with NM Medicaid as a "medical supplier-type 414" Bill under a hospital "professional component" number. Update billing systems to reflect unique features of LARC claims submission. Collaborate with IT on a data-pull format and determine a schedule to analyze data on reimbursement.
IT/EHR	Update EHR with documentation templates and electronic order sets. Work closely with Finance to adapt systems for charge capture. Add LARC to inventory notification systems. Work with Finance to design a data query to confirm appropriate and timely reimbursement.

LARC Implementation: Step 3

Champion Role	Tasks (You Need One Overall Champion)
Clinician	Documents Procedure Flow Training
Pharmacy	Pilot processes, consult Clinicians and IT, and evaluate need for change in: Inventory systems Order process and volume Distribution plan that accounts for need for rapid access to IUDs
Finance	Pilot processes, examine initial date on reimbursement, consult IT, and evaluate the need for change in: Billing systems adjustments made to facilitate LARC claims submission Data-pull format and timing Follow-up on claims denials
IT/EHR	Pilot processes, consult Clinician, Pharmacy, and Finance, and evaluate the need for change in: EHR documentation templates and electronic order sets Systems for charge capture Inventory notification systems Reimbursement and denials data queries to confirm appropriate and timely reimbursement

Adapted from: Hofler, L. G., Cordes, S., Cwiak, C. A., Goedken, P., Jamieson, D. J., & Kottke, M. (2017). Implementing immediate postpartum long-acting reversible contraception programs. Obstetrics & Gynecology, 129(1), 3-9. DOI: 10.1097/AOG.0000000000001798

For Individuals Considering LARC

It is critical that all women have access to up-to-date information that facilitates contraceptive decision-making in the service of full reproductive autonomy. LARC is not appropriate for or appealing to all women, but evidence from the Contraceptive Choice Project shows that LARC methods are popular and have high continuation rates when they are presented among the full range of contraceptive options^vii. Specific resources that may be useful to women seeking information about LARC include:

The Patient counseling resources listed under the For Clinicians heading
Bedsider.org, Method Explorer: https://www.bedsider.org/methods
The CDC’s My Reproductive Life Plan: https://www.cdc.gov/preconception/reproductiveplan.html

Women with private insurance who are considering immediate postpartum LARC should check their benefit plans to confirm that this service would be covered apart from coverage for childbirth. Coverage should be verified during the pregnancy as part of an exploration of all options.

For Clinicians

Clinicians are all the members of the multidisciplinary team that provides direct care and advocacy for women in the hospital, including nurses, physicians, midwives, and lactation consultants. They play a critical role as champions of the effort to establish a LARC program. Clinicians must advocate for IPP LARC as an evidence-based service to their patients. They must have a command of the clinical evidence of efficacy and safety, and the skill set needed to place and remove devices. All members of the clinical team are responsible for providing patient-centered counseling that includes LARC and must document these conversations and procedures in a way that facilitates continuity of care and proper reimbursement. The tools targeted to this audience include:

Clinical Training

Evidence Summaries

Patient Counseling

Templates, Supply Lists & Sample Protocols

For Administrators/
Finance Professionals

Hospital administrators authorize the development of a LARC program. They must understand the program’s value to the institution and to the community. Institutional finance professionals are responsible for implementing the NM Medicaid reimbursement policy through staff training and adjustment of automated billing systems. They will also need to track data and demonstrate successful reimbursement through claims-data monitoring. The tools for administrators and finance professionals specifically address NM Medicaid reimbursement policy and billing and coding guidance based on that policy, including:

State of New Mexico Medicaid Program Manual Supplement #13-05, Subject IV: Insertion of long-acting reversible contraceptives at time of an inpatient delivery stay (2013)

These codes can be billed in addition to the inpatient hospital stay

Insertion of Long Acting Reversible Contraceptives at time of an Inpatient Delivery Stay

For Medicaid recipients – including those eligible for pregnancy-related services only – family planning related services, drug items, supplies, and devices are all covered benefits. This includes the insertion of a long acting birth control device provided in a hospital setting within the delivery stay. The following codes can be billed in addition to the inpatient hospital stay and will be reimbursed at the lesser of the provider’s usual and customary charge or the New Mexico Medicaid fee schedule:

J7300 – Intrauterine copper contraceptive device (e.g. Paragard)
J7298 – Levonorgestrel-releasing intrauterine contraceptive system, (mirena), 52mg
J7307 – Etonogestrel (contraceptive) implant system including implant and supplies (e.g. Nexplanon)
J7301 – Levonorgestrel-Releasing Intrauterine Contraceptive System, (Skyla), 13.5 mg
J7297 – Levonorgestrel-Releasing Intrauterine Contraceptive System, (Liletta), 52 mg
J7296 – Levonorgestrel-Releasing Intrauterine Contraceptive System, (Kyleena), 19.5 mg

Physician supplied long acting birth control devices

A physician billing for the device and the insertion of the device must use a professional claim (837P electronic claim or CMS-1500 form). These services may be billed on the same claim form as the delivery procedure indicating the place of service as 21 (Inpatient Hospital). The correct CPT code for the insertion of the device would most likely be 58300 or 11981. If the provider procured the device, the provider may also bill the HCPC code for the device itself including the NDC number.

The exception to billing for the insertion is if the device is placed within the same surgery as a cesarean section, the insertion is considered incidental and the provider may only bill for the device.

Hospital supplied long acting birth control devices

If the hospital supplies the device, the hospital facility must be enrolled in the New Mexico Medicaid program as a medical supplier (provider type 414) in order to be paid for the device for the same date of service covered by the DRG payment. As a medical supply company the facility will be required to submit a professional claim (837P electronic claim or CMS-1500 form) with the appropriate HCPCs procedure code for the device itself including the NDC number, using Place of Service code 21 (Inpatient Hospital). Also, be sure to include the billing taxonomy number for a medical supplier on the claim, which is typically 332BOOOOOX.

It is not necessary for a hospital to have a separate distinct NPI as a medical supply provider if the device is billed as professional claim (837P electronic claim or CMS-1500 form) and the medical supply taxonomy is submitted on the claim.

If you have questions regarding the above information, you may contact the Medicaid Program Policy and Integrity Bureau at (505) 827-3171.

For Hospital Pharmacists

Hospital Pharmacists play a critical role in the logistics of IPP LARC provision. They maintain responsibility for ordering and stocking devices through established processes that may need to be adjusted in order to accommodate LARC. Pharmacists must assure that IUDs are accessible to clinicians around the clock for post-placental placement at the time of birth. Contraceptive implant placement is less time-sensitive. Pharmacists must also understand the evidence supporting LARC safety and efficacy. The role of pharmacists is outlined in each step of the implementation guide. Specific resources that may be useful to pharmacists include:

Evidence summaries listed under the For Clinicians heading
State of New Mexico Medicaid Program Manual Supplement #13-05 content on inpatient
LARC listed under For Administrators/Finance Professionals

For Information Technology Professionals

IT professionals play a critical role in supporting the work of every other department involved with IPP LARC provision. Every step from device ordering and stocking, to clinical documentation, to coding and billing will require IT involvement in order to capture and communicate necessary information between departments and with outside vendors and payers. The role of IT professionals is outlined in each step of the implementation guide. Specific resources that may be useful to IT professionals include:

Clinical documentation templates for post-placental IUD insertion and implant insertion listed under the For Clinicians heading
The impatient LARC coding and troubleshooting guides listed under For Administrators/ Finance Professionals

Lessons Learned to Date

While our experience is far from complete, our work with partner hospitals to implement IPP LARC programs has yielded some important lessons. We continue to refine our guidance, tools, and technical assistance. Click on each lesson for details on what we have learned.

1) A clinical champion is critical.

2) Policy change without promotion and technical assistance may have little impact on practice.

The Medicaid policy allowing for reimbursement for LARC outside of the global fee for childbirth was relatively unknown until our work began. In the current healthcare environment, few hospitals are able to track all the potential changes to traditional ways of providing and billing for services. Without hospital engagement and feedback, the Medicaid Program cannot understand the utility and clarity of its policy guidance. Programs like ours are able to create and maintain a feedback loop that is mutually beneficial to hospitals and Medicaid.

3) In the current complex hospital environment, all stakeholders should be engaged early in the process

4) Regular examination of claims data is essential to confirm that billing is being submitted and reimbursed appropriately

Errors are always possible and resolvable, but not without data to identify problems and patterns. We are confident that the groundwork pursued with UNM Hospital has allowed the Centennial Care MCOs to configure their systems to pay for LARC in addition to the DRG for childbirth. The Centennial Care Contracts Bureau has been consistently receptive to feedback, and has taken the lead in resolving any issues around appropriate to providing assistance with any billing reimbursement. We remain committed to providing assistance with any billing concerns.

5) There is tremendous capacity within our local healthcare institutions to innovate and assist women in meeting their reproductive life plan goals.

References

ⁱ Hofler, L. G., Cordes, S., Cwiak, C. A., Goedken, P., Jamieson, D. J., & Kottke, M. (2017). Implementing immediate postpartum long-acting reversible contraception programs. Obstetrics & Gynecology, 129(1), 3-9. DOI: 10.1097/AOG.0000000000001798

ⁱⁱ Heberlein, E., Billings, D.L., Mattison-Faye, A. & Giese, BZ(M). (2016). The South Carolina Postpartum LARC Toolkit. Choose Well Initiative & the South Carolina Birth Outcomes Initiative.

ⁱⁱⁱ Vernon K. Smith, Kathleen Gifford, Eileen Ellis, and Barbara Edwards, Health Management Associates; and Robin Rudowitz, Elizabeth Hinton, Larisa Antonisse & Allison Valentine, Kaiser Commission on Medicaid and the Uninsured. Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017, The Henry J. Kaiser Family Foundation, October 2016.

^iv Kost K, Unintended Pregnancy Rates at the State Level: Estimates for 2010 and Trends Since 2002, New York: Guttmacher Institute, 2015,.

^v ACOG (2016). Committee Opinion #670: Immediate Postpartum Long-Acting Reversible Contraception.

^vi Dehlendorf, C., Henderson, J. T., Vittinghoff, E., Grumbach, K., Levy, K., Schmittdiel, J., … & Steinauer, J. (2016). Association of the quality of interpersonal care during family planning counseling with contraceptive use. American journal of obstetrics and gynecology, 215(1), 78-e1.

^vii Birgisson, N. E., Zhao, Q., Secura, G. M., Madden, T., & Peipert, J. F. (2015). Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. Journal of Women’s Health, 24(5), 349–353. http://doi.org/10.1089/jwh.2015.5191

Acknowledgements

We wish to thank a number of individuals and agencies that made this toolkit possible. First and foremost, we owe a debt of gratitude to the physicians, midwives, and nurses who provide care to childbearing women in hospitals throughout New Mexico. We appreciate the willingness of clinicians to engage with us to consider what it would take to offer postpartum LARC, and to provide the advocacy necessary to make needed systems changes occur. In particular, we want to acknowledge Gail Stamler, CNM, Beatris Barrera, MD, Megan Henry, MD and Jennifer Jaggi, MD for their leadership. Erica Archuleta, NM Human Services Department, has been an essential partner within the NM Medicaid Program. Erica provided the institutional accountability around reimbursement that has made it possible to engage hospitals, and without that support, there would have been no need for a toolkit at all! April Neri, RN, Nurse Consultant for the NM Family Planning Program designed a protocol for NM Title X clinics that provided a useful template for some of the tools. April also coordinated our Contraceptive Access Learning Community State Team. Valuable support and technical assistance was provided to the state team by the Association of State and Territorial Health Officials (ASTHO) http://astho.org/Programs/Maternal-and-Child-Health/Long-Acting-Reversible-Contraception-LARC/. This toolkit, although designed for NM community hospitals, owes a significant debt to toolkits designed by the Georgia Perinatal Quality Collaborative (GPQC)[i] and by Choose Well SC and the South Carolina Birth Outcomes Initiative[ii]. The development and deployment of this toolkit has been funded by a generous grant from the National Institute for Reproductive Health (NIRH).

LARC Toolkit

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