Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.07-048 - Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD) - Provider Manual Update Transmittal #113

Universal Citation: AR Admin Rules 016.06.07-048

Current through Register Vol. 49, No. 9, September, 2024

Section II Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)

216.400 Sterilizations
A. Medicaid covers sterilization of men and women.
1. All adult (aged 21 or older) male and female Medicaid beneficiaries who are mentally competent are eligible for therapeutic and non-therapeutic sterilization procedures.

2. Adult (aged 21 or older) women who participate in the Women's Health (Family Planning Waiver) Program (Aid Category 69) and who are mentally competent are eligible for non-therapeutic sterilization procedures approved by CMS for the Women's Health Program and for non-therapeutic sterilizations not performed in conjunction with deliveries of infants.

B. Medicaid coverage of elective, non-therapeutic sterilization is contingent upon the provider's documented compliance with federal and state regulations, including obtaining the patient's signed consent in the manner prescribed by law.

C. A non-therapeutic sterilization is any procedure or operation for which the primary purpose is to render an individual permanently incapable of reproducing.
1. Non-therapeutic sterilization is neither
a. A necessary part of the treatment of an existing illness or injury nor

b. Medically indicated as an accompaniment of an operation of the genitourinary tract.

2. The reason the individual decides to take permanent and irreversible action is irrelevant. It may be for social, economic or psychological reasons, or because a pregnancy would be inadvisable for medical reasons.

D. Prior authorization is not required for a sterilization procedure. However, all applicable criteria described in this manual must be met.

E. Federal regulations are very explicit concerning coverage of non-therapeutic sterilization.
1. The person to be sterilized must voluntarily request the service.

2. The person must be mentally and legally competent to give informed consent.

3. The person must be 21 years of age or older when he or she gives informed consent.

4. The person to be sterilized shall not be an institutionalized individual. The regulations define "institutionalized individual" as a person who is a. Involuntarily confined or detained under a civil or criminal statute in a correctional or rehabilitative facility, including a facility for mental illness, or b. Confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.

5. The person has been counseled, both orally and in writing, regarding alternative methods of birth control and the effects and the impact of sterilization.

6. Informed consent and counseling must be properly documented. Only the official Sterilization Consent Form DMS-615, correctly completed, complies with documentation requirements. View or print Sterilization Consent Form DMS-615 and Checklist.
a. Copies may be ordered from EDS. View or print EDS supplied forms information. See Section V of any Arkansas Medicaid provider manual for forms and instructions for ordering forms and publications.

b. If the patient needs the Sterilization Consent Form in an alternative format, such as large print, contact our Americans with Disabilities Act Coordinator.

V iew or print ADA Coordinator contact information.

7. Available by order from EDS are two free informational publications: Sterilization Consent Form-Information for Women (PUB-019) and Sterilization Consent Form-Information for Men (PUB-020). View or print a list of EDS supplied forms. See Section V of any Arkansas Medicaid provider manual for forms and instructions for obtaining forms and publications.

8. If you have any questions regarding any of these instructions, contact the Arkansas Medicaid Program before the sterilization.

272.150 Family Planning Services
A. Arkansas Medicaid covers numerous family planning services-including contraceptive devices and supplies-for both male and female beneficiaries who have full Medicaid coverage.

B. Women in the Pregnant Women-Poverty Level Program (PWPL, Aid Category 61) are eligible for all family planning services until the last day of the month in which the 60th postpartum day occurs.

C. Women who participate in the Women's Health (Family Planning Waiver) Program (Aid Category 69) are eligible for most of Medicaid's family planning services. Services that are not covered for Women's Health Program participants are listed in section 272.157.

D. A family planning diagnosis code must be the primary (first) diagnosis code on a claim for family planning services.
1. Institutional billing forms do not permit entry of a diagnosis for each service billed.

2. Bill for family planning services and non-family planning services on separate claims, whether the claims are paper or electronic.

272.151 Outpatient Hospital Visits for Family Planning

Procedure Code

Modifier

Description

99402

UA

Basic Family Planning Visit-Facility Fee

99401

UA

Periodic Family Planning Visit-Facility Fee

272.152 Family Planning Procedures

This section lists procedure codes for covered family planning procedures.

A. Some procedures are performed for both family planning and non-family planning purposes.

B. Procedure codes followed by asterisks require a primary diagnosis of family planning or elective non-therapeutic sterilization unless the surgery is medically necessary.

C. CPT procedure codes 58661 and 58700 represent procedures to treat medical conditions as well as for elective sterilizations. When billing with either of these codes for treatment of a medical condition, submit a paper claim and attach the operative report.

Family Planning Surgery Procedure Codes

11975

11976

11977

55250

55450

58300

58301

58565

58600

58605

58611

58615

58661*

58670

58671

58700*

272.153 Family Planning Laboratory Procedure Codes

When billing for family-planning related lab, use only family-planning related diagnosis codes on the claim.

81000

81001

81002

81003

81025

83020

83520

83896

84703

85014

85018

85660

86592

86593

86687

86701

87075

87081

87088

87210

87390

87470

87490

87491

87536

87590

87591

87621

88142*

88143*

88147

88148

88150

88152

88153

88154

88155

88164

88165

88166

88167

88174

88175

88302

89300

89310

89320

Q0111

This lab procedure is covered only once per beneficiary per state fiscal year, July 1 through June 30.

272.154 Contraceptive Devices

Procedure Code

Description

J1055

Medroxyprogesterone acetate for contraceptive use

J7300

Intrauterine copper contraceptive

J7302

Levonorgestrel-releasing intrauterine contraceptive system

J7303

Contraceptive supply, hormone containing vaginal ring

J7306

Levonorgestrel (contraceptive) implant system, including implants and supplies

272.155 Essure Procedure and Related Services
A. Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants ("Essure"), procedure code 58565, is a family planning service.

B. Unlike other sterilization procedures, the Essure procedure requires additional procedures for up to 6 months.
1. Three of these procedures-represented by procedure codes J1055,11976 and 58301-are family planning services that usually are not covered after a sterilization procedure, but they are covered after the initial hysteroscopy as components of the Essure procedure

2. Additionally, five procedures (58340, 58345, 72190, 74740 and 74742) that usually are not covered as family planning services are covered as family planning services when performed within six months of the initial hysteroscopy.

272.156 Surgical Pathology-Examination of Tissue

Use procedure code 88302 to bill Medicaid the hospital's charges for surgical pathology related to outpatient elective sterilization.

272.157 Family Planning Procedures Not Covered for Women in the Women's Health (Family Planning Waiver) Program

Women in the Women's Health (Family Planning Waiver) Program (Aid Category 69) are not eligible for the services represented by the procedure codes in this section.

Procedures not Covered for Women in Aid Category 69

55250

55450

58605

58611

58661

58700

89300

89310

89320

S0612

Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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