CPT CODE and Description
CPT Code 58661 – Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
AMA Guidelines
•Code 58661 describes a bilateral procedure, it would not be necessary to append Modifier 50 to indicate the procedure was performed bilaterally and it is not necessary to report modifier 52, Reduced Services for the removal of an ovary and/or fallopian tube on one side
CMS Guidelines
•CPT code 58661 has a status indicator of “1” in the Modifier -50 field indicating that a 150% payment adjustment applies for bilateral procedures
Common reasons sterilization claims are denied
- A copy of the consent form is NOT attached.
- There are blank lines on the consent form. (All lines in sections I, II, and IV must be completed, except lines 21, 22, and 23 which are required only in certain
cases.) - Lines are not completed correctly on the consent form, or inaccurate information is included rather than what is needed.
- On the consent form, there are fewer than 30 days from the date of the client’s signature (line 8) to the date of the sterilization operation (line 19).
- The sterilization date on the consent form (line 19) is not the same as the sterilization date on the claim.
- The provider who signs the consent form (line 24) is not the provider listed on the claim as performing the sterilization procedure.
- The provider’s signature is illegible on the consent form and the provider’s name is not printed above his or her signature (line 24).
- The handwriting on the consent form is illegible or the photocopy quality is too poor to read.
- No expected date of delivery is listed with a premature delivery (line 22).
- The client consents to surgical sterilization and a hysteroscopic sterilization on the same consent form (tubal ligation and ESSURE).
- Salpingectomy (procedure code 58661 or 58700) is billed as a sterilization but tubal ligation is listed as the specific type of operation (line 20).
Service:
Contraceptive Methods and Counseling HRSA Recommendation December 2019 The Women’s Preventive Services Initiative recommends that adolescent and adult women have access to the full range of female-controlled contraceptives to prevent unintended pregnancy and improve birth outcomes. Contraceptive care should include contraceptive counseling, initiation of contraceptive use, and follow-up care (e.g., management, and evaluation as well as changes to and removal or discontinuation of the contraceptive method). The Women’s Preventive Services Initiative recommends that the full range of female-controlled U.S. Food and Drug Administration-approved contraceptive methods, effective family planning practices, and sterilization procedures be available as part of contraceptive care. The full range of contraceptive methods for women currently identified by the U.S. Food and Drug Administration include: (1) sterilization surgery for women, (2) surgical sterilization via implant for women, (3) implantable rods, (4) copper intrauterine devices, (5) intrauterine devices with progestin (all durations and doses), (6) the shot or injection, (7) oral contraceptives (combined pill), 8) oral contraceptives (progestin only, and), (9) oral contraceptives (extended or continuous use), (10) the contraceptive patch, (11) vaginal contraceptive rings, (12) diaphragms, (13) contraceptive sponges, (14) cervical caps, (15) female condoms, (16) spermicides, and (17) emergency contraception (levonorgestrel), and (18) emergency contraception (ulipristal acetate), and additional methods as identified by the FDA. Additionally, instruction in fertility awareness-based methods, including the lactation amenorrhea method, although less effective, should be provided for women desiring an alternative method.
Procedure Code(s):
A4268, A4269, 57170, 74740, 96372, 11976, 11981, 11982, 11983, 58300, 58301, A4261, A4264, A4266, S4981, S4989, J1050, J7297, J7298, J7300, J7301, J7303, J7304, J7306, J7307, 58600, 58605, 58611, 5865, 58661, 58565, 58670, 58671, 58340, J7296
Additional Reimbursement Criteria:
Contraception methods that require a prescription may be covered under the patient’s medical or pharmacy benefit. For details about pharmacy benefit coverage for contraception, contact the number on the patient’s BCBS member card. A patient’s pharmacy benefit may be managed by a company other than BCBS.
Visits pertaining to contraceptive counseling, initiation of contraceptive use, and follow-up care may also apply to procedure codes under HRSA’s ‘Well-Woman’ recommendation
Procedure code 58340 reimbursable at the preventive level only when accompanied with modifier 33 or one of the following diagnosis codes: Z30.2, Z30.40, Z30.42, Z30.49, Z98.51, Procedure codes 11981, 11982, and 11983 (are covered only when FDA approved contraceptive implant insertion or removal are performed) are reimbursable at the preventive level when billed with one of the following diagnosis codes: Z30.013, Z30.017, Z30.018, Z30.019, Z30.09, Z30.40, Z30.42, , Z30.46, Z30.49, Z30.8, Z30.9
Procedure code 58661 reimbursable at the preventive level with a diagnosis of Z30.2
- CPT codes 58661 and 58700 represent procedures to treat medical conditions as well as for elective sterilizations. When filing paper claims for either of these services for elective sterilizations, enter type of service code “A”. When using either of these codes for treatment of a medical condition, type of service code “2” must be entered for the primary surgeon or type of service code “8” for an assistant surgeon.
Description
This policy describes the medical necessity requirements for the removal of Essure®, a permanent birth control method that involves the bilateral placement of coils into the fallopian tubes which results in the development of scar tissue and occlusion of the fallopian tubes.
Policy/Criteria
I. It is the policy of Pennsylvania Health and Wellness® that the removal of Essure is medically necessary when meeting all of the following:
A. Member is having symptoms related to the device such as abdominal/pelvic pain or heavy/irregular menses not related to other gynecologic pathologies, device migration, or nickel allergy/hypersensitivity;
B. Performed by a gynecologist or surgeon experienced in removing the device;
C. Radiologic evaluation to determine the device location;
D. One of the following procedures:
- Hysteroscopy if = 7 weeks post-placement;
- Laparoscopy or laparotomy for one of the following:
a. Linear salpingotomy, salpingostomy, or salpingo-oophorectomy;
b. Cornual resection and repair;
c. Removal of devices that have migrated from the fallopian tubes.
Background
Essure is a form of permanent birth control that can be performed in an office setting and does not require incisions or general anesthesia. It involves the placement of spring-like devices into the proximal section of each fallopian tube via hysteroscopy. Over the next three months, scar tissue forms around the Essure coils facilitating insert retention and pregnancy prevention. The build-up of tissue creates a barrier to block sperm from reaching the eggs, preventing pregnancy.
Over the past several years, a growing number of adverse events have been report to the FDA (Food and Drug Administration) associated with the use of Essure. Frequently reported adverse events include pain/abdominal pain, menstrual irregularities, headache, fatigue, device migration, allergy/hypersensitivity reaction, and weight fluctuations. Because of these reported adverse events, there has been an increase in the number of women seeking removal of the Essure device.
Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2017, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services
GENERAL CLAIMS/BILLING GUIDELINES FOR ALL PLANS
*Z30.430 – Encounter for insertion of intrauterine contraceptive device
*Z30.432 – Encounter for removal of intrauterine contraceptive device
*Z30.433 – Encounter for removal and reinsertion of intrauterine contraceptive device
*Z30.49 – Encounter for surveillance of other contraceptives
*Z30.8 – Encounter for other contraceptive management
*Z30.9 – Encounter for contraceptive management, unspecified
*Z31.42 – Aftercare following sterilization reversal
*Z31.62 – Encounter for fertility preservation counseling
*Z31.84 – Encounter for fertility preservation procedure
• Any service billed with a modifier of FP will be paid as family planning (if the modifier is valid for the code).
• The following codes will always be paid as family planning regardless of the diagnosis or presence of the FP modifier:
CODE DESCRIPTION
58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES
