Due to confusion with the language in the Jan. 1, 2021, posting of Clinical Coverage Policy 1A-22, Medically Necessary Circumcision, the policy has been revised with grammar and punctuation updates, and posted with an effective date of May 15, 2021, on the Physician Clinical Coverage Policies page of the NC Medicaid website.
NC Medicaid, per policy (and legislation), pays for medically necessary circumcisions. The policy covers medical necessity for the two different age groups covered by CPT – newborn and non-newborn. NC Medicaid added preventive language to the policy; however, the determination for medical necessity (including for HIV prevention) lies between the family requesting the circumcision and the physician.
Effective Jan. 1, 2021, medical necessity for newborn circumcisions has been updated to include any of the following:
- Congenital obstructive urinary tract anomalies
- Neurogenic bladder
- Spina bifida
- Urinary tract infections
- Prophylaxis for Human Immunodeficiency Virus (HIV)
Effective Jan. 1, 2021, medical necessity for non-newborn circumcisions has been updated to include any of the following:
- A documented prior history of recurrent urinary tract infections
- Documented vesicoureteral reflux of at least a Grade III
- Paraphimosis
- Recurrent balanoposthitis
- Recurrent balanitis or balanitis xerotica obliterans
- Congenital chordee
- True phimosis causing urinary obstruction, hematuria, or preputial pain for a beneficiary age six and older
- Secondary or acquired phimosis causing urinary obstruction, hematuria, or preputial pain unresponsive to medical therapy
- Condyloma acuminatum
- Malignant neoplasm of the prepuce
- Prophylaxis for Human Immunodeficiency Virus (HIV)
Effective Jan. 1, 2021, providers billing for medically necessary circumcisions performed for the prevention of disease for newborn and non-newborn male beneficiaries should submit diagnosis Z29.8 (encounter of other specified prophylactic measures) and an appropriate circumcision procedure code.
Providers are encouraged to review Clinical Policy 1A-22, Medically Necessary Circumcision on the Physician Clinical Coverage Policies page of the NC Medicaid website for other general language and formatting updates.
Contact
NC Medicaid Contact Center 888-245-0179