Medicare Essure Procedure Scenario

Published: 15th March 2011
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Which ICD-9 code would you use here?



In a particular scenario, one of our ob-gyns carried out an Essure procedure on a Medicare patient for recurrent situational anxiety of pregnancy.



Medicare doesn't compensate for sterilization under this condition. You should think about this service (58565, Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants) as an elective procedure. You should always write V25.2 (Sterilization) as the key diagnosis; however you can list her mental condition secondary (for instance 300.02, generalized anxiety disorder).



Advance Beneficiary Notice (ABN): Your provider should have the patient sign an ABN accepting she agrees to have the service carried out and will be responsible if not covered by Medicare. Report the services to Medicare with the GA modifier (Waiver of liability statement on file) added to the CPT codes indicating that the provider has a signed ABN form on file for this service. If the service is actually not covered owing to medical necessity, the GA modifier will allow Medicare to transfer the billed amount to patient responsibility rather than your provider's responsibility. You should report the GA modifier only when an ABN form was presented to the patient before the sterilization procedure was carried out.



Medicare coverage rules for sterilization:



Payment may be made only where sterilization is an important part of the treatment of an illness or injury; example, removal of a uterus because of a tumor or removal of diseased ovaries. Sterilization of a mentally retarded beneficiary is covered if it's a vital part of the treatment of an illness or injury, (bilateral oophorectomy), or bilateral orchidectomy in a case of cancer of the prostate. The contractor denies claims when the pathological evidence of the necessity to carry out any such procedures to tend to an illness or injury is absent; and monitor such surgeries closely and get the information needed to find out whether in fact the surgery was carried out as a means of treating an illness or injury or only to achieve sterilization.



A sterilization that's carried out because a doctor believes another pregnancy would endanger the overall general health of the woman is not considered to be reasonable and necessary for the diagnosis treatment of illness or injury within the meaning of 1862(a)(1) of the Act. The same conclusion would apply where the sterilization is carried out only as a measure to prevent the possible development of, or effect on, a mental condition should the individual become pregnant; and sterilization of a mentally retarded person where the purpose is to prevent conception rather than the treatment of an illness or injury.



ICD-10: In 2013, when your diagnosis system changes, you will report the following equivalents:



  • V25.2 = Z3.2 (Encounter for sterilization)

  • 300.02 = F41.1 (Generalized anxiety disorder)



    For more on this and for other specialty-specific articles to assist your ob-gyn coding, sign up for a good medical coding resource like Coding Institute.




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