Here’s an ob-gyn coding scenario you might run into: “One of our ob-gyns carried out an essure procedure on a Medicare patient for recurrent situational anxiety of pregnancy. What ICD-9 code should I report here?”
Medicare doesn’t pay for sterilization under this condition. You should think about this particular service (58565, Hysteroscopy, surgical; with bilateral fallopian tube cannulation to persuade occlusion by placement of permanent implants) as an elective procedure. You should at all times list V25.2 (Sterilization) as the primary diagnosis; but then you can list her mental condition secondary (e.g 300.02, generalized anxiety disorder).
Advance Beneficiary Notice (ABN): Your provider should have the patient sign an ABN acknowledging she agrees to have the service performed and will be responsible if not covered by Medicare. Report the services to Medicare with the GA modifier (waiver of liability statement on file) appended to the CPT codes indicating that the provider has a signed ABN form on file for this service. If the service is indeed 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 use the GA modifier only when an ABN form was presented to the patient prior to the sterilization procedure was carried out.
Medicare coverage rules for sterilization
Payment may be made only where sterilization is a vital part of the treatment of an illness or injury; for instance, removal of a uterus because of a tumor or removal of diseased ovaries. Sterilization of a mentally retarded beneficiary is covered if it’s an important 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 hold of the information required to determine 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 performed as a physician thinks another pregnancy wound put in danger the overall general health of the woman is not considered reasonable and necessary for the diagnosis or 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 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: When your diagnosis system changes in a couple of years’ time, you will report the following equivalents:
V25.2 = Z3.2 (Encounter for sterilization)
300.02 = F41.1 (Generalized anxiety disorder)
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