Clinical Policy 1E-3, Sterilization Procedures, has been revised and will post Aug. 15, 2020 on the NC Medicaid website.
1. Sterilization Consent form Abbreviation Modification for Bilateral Postpartum Sterilization
Effective Aug. 15, 2020, the abbreviation for Bilateral postpartum sterilization will change from BPS to BPPS for use on the sterilization consent form.
Consent forms signed prior to the Aug. 15, 2020 effective date with the abbreviation “BPS” for Bilateral Postpartum Sterilization will be accepted for 180 days from the Aug. 15 effective date.
2. Revenue Codes
The table of revenue codes in Clinical Policy 1E-3, Sterilization Procedures has been updated to remove revenue codes associated with the non-covered Essure procedure and add revenue codes associated with sterilization procedures covered in policy.
3. Essure CPT Codes and Associated Guidelines
- Effective Aug. 15, 2020, Essure CPT code 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants) will be removed from Clinical Policy 1E-3, Sterilization Procedures. This code was made non-covered by NC Medicaid effective Dec. 31, 2018.
- Effective Aug. 15, 2020, CPT code 58340 (catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography) will be removed from Clinical Policy 1E-3, Sterilization Procedures. This code was made non-covered by NC Medicaid effective May 1, 2019.
- Effective Aug. 15, 2020, Essure related CPT codes 58579 (Unlisted hysteroscopy procedure, uterus) and 74740 (Hysterosalpingography, radiological supervision and interpretation) will be removed from policy as Essure sterilization procedure is no longer a covered service by NC Medicaid. CPT code 74740 will be made non-covered by NC Medicaid effective Aug. 1, 2020.
- Effective Aug. 15, 2020, the definition of Hysteroscopic Procedure and all guidelines associated with the Essure procedure will be removed from Clinical Policy 1E-3, Sterilization Procedures.
4. Prophylactic Bilateral Salpingectomy
Effective Aug. 15, 2020, prophylactic salpingectomy procedures will be covered for North Carolina Medicaid beneficiaries as a sterilization procedure. Studies suggest that total removal of the tubes at the time of sterilization could result in a lower risk of developing ovarian cancer. The following CPT codes will be added to Clinical Policy 1E-3, Sterilization Procedures in Attachment A.
- 58661 - Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
- 58700 - Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
Diagnosis code for elective prophylactic salpingectomy
Z30.2 - Encounter for sterilization
In addition, the following associated abbreviations and acceptable written wording for use on the sterilization consent form have been added to Clinical Policy 1E-3, Sterilization Procedures in Attachment B.
PBS – Prophylactic bilateral salpingectomy
Acceptable written wording
Prophylactic bilateral salpingectomy
Providers are encouraged to review Clinical Policy 1E-3, Sterilization Procedures for general language and formatting updates and guidance on billing and completing the sterilization consent form prior to performing a Prophylactic bilateral salpingectomy.
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