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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 2 Medicaid Title XIX Family Planning Services : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.5 Contraceptive Devices and Related Procedures
2.2.5
Contraceptive Devices and Related Procedures
2.2.5.1
External Contraceptives
Procedure codes A4261 (cervical cap) and A4266 (diaphragm) may be reimbursed separately from the fitting and instruction (procedure code 57170).
Procedure codes A4261 and A4266 may be reimbursed when they are billed with one of the following diagnosis codes:
 
Diagnosis Codes
Z30011
Z30012
Z30018
Z3009
Z302
Z3040
Z3041
Z3042
Z30431
Z30432
Z3049
Z308
Z309
Z641
Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.