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2012 Texas Medicaid Provider Procedures Manual

Gynecological and Reproductive Health and Family Planning Services Handbook : 3. Women’s Health Program (Title XIX Family Planning) : 3.3 Services, Benefits, Limitations, and Prior Authorization : 3.3.8 Sterilization and Sterilization-Related Procedures : Hysteroscopic Sterilization
Providers must use procedure code 58340 or procedure code 58565 with diagnosis code V252 to submit claims for the fallopian tube occlusion sterilization. Procedure code 58565 is considered bilateral.
The occlusive sterilization system (micro-insert) is a benefit when billed with procedure code A4264. Procedure code A4264 may be reimbursed for females 10 years through 55 years of age.

Texas Medicaid & Healthcare Partnership
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