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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

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:

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