Part B Insider (Multispecialty) Coding Alert

Question: One of our ob-gyns did an Essure procedure on a Medicare patient for recurrent situational anxiety of pregnancy. What ICD-9 code should I report?

Answer: Medicare does not pay for sterilization under this condition. You should consider 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 list V25.2 (Sterilization) as the primary diagnosis, but you can list her mental condition secondary (for instance, 300.02, Generalized anxiety disorder).

ABN: Your provider should have the patient sign an advance beneficiary notice (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 due 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 performed.

Medicare coverage rules for sterilization are as follows:

Payment may be made only where sterilization is a necessary part of the treatment of an illness or injury, e.g., removal of a uterus because of a tumor or removal of diseased ovaries. Sterilization of a mentally retarded beneficiary is covered if it is a necessary 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 perform any such procedures to treat an illness or injury is absent; and Monitor such surgeries closely and obtain the information needed to determine whether in fact the surgery was performed as a means of treating an illness or injury or only to achieve sterilization.

A sterilization that is performed because a physician believes another pregnancy would endanger the overall general health of the woman is not considered to be 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 performed 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.