LCD Reference Article Article

Sterilization

A53356

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A53356
Original ICD-9 Article ID
Not Applicable
Article Title
Sterilization
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
04/12/2018
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

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Article Guidance

Article Text
Sterilization means any medical procedure, treatment or operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged/dysfunctional body part.

Under the Medicare Program guidelines the coverage of sterilization is limited to necessary treatment of an illness or injury. An example of necessary treatment is the removal of a uterus or removal of diseased ovaries (bilateral oophorectomy) because of a tumor, or bilateral orchiectomy in the case of prostate cancer.

Elective hysterectomy, tubal ligation and vasectomy in the absence of a disease for which sterilization is considered an effective treatment is not covered. In addition, no payment would be made for sterilization procedures if it is a preventive measure e.g., a physician believes pregnancy would cause overall endangerment to a woman's health, or as a measure to prevent the possible development of, or effect on a mental condition, should pregnancy occur. (Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k).

Claims will be denied on postpay review and payment recouped if the pathological evidence of the necessity to perform any of these procedures to treat an illness or injury is absent and/or when the primary objective is to achieve sterilization.



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Coding Information

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-CM code Z30.2, sterilization should be noted in Item 24E of the CMS-1500 claim form or the electronic equivalent:

Group 1 Codes
Code Description
Z30.2 Encounter for sterilization
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ICD-10-PCS Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/12/2018 R4

Updated to indicate this article is not an LCD Reference Article.

04/12/2018 R3

Article converted to Billing and Coding. No change is coverage was made.

04/12/2018 R2

This Article effective 4/12/2018 combines JEA A53355 in to JEB A53356 so that both JEA and JEB contract numbers will have the same final Medicare Coverage Article (MCA) number.

10/01/2015 R1 Consistency among Noridian Jurisdictions
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
11/16/2023 04/12/2018 - N/A Currently in Effect You are here
09/29/2020 04/12/2018 - N/A Superseded View
04/02/2018 04/12/2018 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Sterilization
  • Vasectomy
  • Tubal
  • Ligation
  • Vaginal
  • Fallopian
  • Oviduct
  • hysterectomy
  • 55250
  • 58600
  • 58605
  • 58611
  • 58615
  • 58670
  • 58671