Sterilization

Sterilization means any medical procedure, treatment or operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged/dysfunctional body part.

Under the Medicare Program guidelines the coverage of sterilization is limited to necessary treatment of an illness or injury. An example of necessary treatment is the removal of a uterus or removal of diseased ovaries (bilateral oophorectomy) because of a tumor, or bilateral orchiectomy in the case of prostate cancer.

Elective hysterectomy, tubal ligation and vasectomy in the absence of a disease for which sterilization is considered an effective treatment are not covered. In addition, no payment would be made for sterilization procedures if it is a preventive measure e.g., a physician believes pregnancy would cause overall endangerment to a woman's health, or as a measure to prevent the possible development of, or effect on a mental condition, should pregnancy occur. (Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k)).

Claims will be denied on post pay review and payment recouped if the pathological evidence of the necessity to perform any of these procedures to treat an illness or injury is absent and/or when the primary objective is to achieve sterilization.

The following procedures, when used for sterilization to prevent reproduction, will be auto-denied due to the absence of a Medicare benefit category.

CPT Code Description
55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)
58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (list separately in addition to code for primary procedure)
58615 Occlusion of fallopian tube(s) by device (eg, band, clip, falope ring) vaginal or suprapubic approach
58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or falope ring)

 

ICD-10-CM code Z30.2, sterilization should be noted in Item 24E of the CMS-1500 claim form or the electronic equivalent:

ICD-10-CM Code Description
Z30.2 Encounter for sterilization

 

Effective Date Changes Implemented
10/01/2015 Consistency among the Noridian Jurisdictions

 

Last Updated Jan 12, 2018