016-06-09 Ark. Code R. § 24

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.09-024 - Official Notice DMS-2009-A-1, DMS-2009-X-1, DMS-2009-II-1, DMS-2009-L-1, DMS-2009-R-1 - Billing for Essure Procedure and Device

I. Background

CPT procedure code 58565 (Essure) is a covered family planning sterilization procedure for both family planning only beneficiaries (Aid Category 69) and regular Medicaid beneficiaries. However, effective for dates of service on and after August 31, 2009, billing protocols are changed to allow providers to bill and be reimbursed for the portion of the service that they provide when this method of sterilization is chosen. Billing may be for the procedure, provision of the device, or both.

II. Billing Protocol

All providers are to separate their charges when billing for:

1)Performance of the "procedure", "Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-PROCEDURE ONLY" (CPT procedure code 58565). This service includes all supplies except provision of the device. Claims must be billed on paper with a correct DMS-615 attached.

2)Provision of the implant "device"for: "Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-DEVICE ONLY" Claims may be billed electronically or on paper. NOTE: Payment of the claim for the "device" will not be made without a paid or pending Essure "procedure" claim.

III.Professional Claims

Bill for physicians' claims using the following protocol:

A. See below the procedure code, required modifier(s), and descriptions for non-hospital-based physician and FQHC claims related to Essure. NOTE: The device is only billable when provided in the physician's office place of service.

Procedure Code	Modifier	Procedure Description
58565	FP	"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-PROCEDURE ONLY"
58565	FP, U1	"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-DEVICE ONLY"

B. See below the procedure code and description for hospital-based physician claims for the Essure procedure.

Procedure Code	Modifier	Procedure Description
58565	none	"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-PROCEDURE ONLY"

IV.Facility Claims

Bill for hospital-based outpatient clinics, ambulatory surgical centers, and outpatient hospital

claims using the following protocol:

A.Hospital-based outpatient clinics may bill for the Essure procedure and provision of the device as shown below.

Procedure Code	Modifier	Procedure Description
58565	U3	"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-PROCEDURE ONLY"
58565	U2	"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-DEVICE ONLY"

B.Ambulatory surgical centers and outpatient hospitals may bill for the Essure procedure and device following the protocol below:

Procedure Code	Modifier	Procedure Description
58565	U3	"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-PROCEDURE ONLY"
58565	U1	"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-DEVICE ONLY"

All post-Essure coverage policy and billing protocols are unchanged. No other family planning services are changed. All other billing requirements must be met in order to be reimbursed for these services.

Thank you for your participation in the Arkansas Medicaid Program.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at 501-682-8323 (Local); 1-800-482 -5850, extension 2-8323 (Toil-Free) or to obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY Hearing Impaired).

If you have questions regarding this notice, please contact the EDS Provider Assistance Center at In-State WATS 1 - 800-457-4454, or locally and Out-of-State at (501) 376-2211.

Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

016.06.09 Ark. Code R. § 024

11/16/2009