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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 : 2.2.8 Sterilization and Sterilization-Related Procedures : Occlusive Sterilization Device
Procedure code A4264 may be reimbursed for the occlusive sterilization system (micro-insert), and may be reimbursed separately from the surgery (procedure code 58565) to place the device.
Providers must bill procedure code A4264 on the same date of service by the same provider as the occlusive sterilization system (micro-insert).
Procedure code 58565 is considered bilateral and is limited to once per lifetime, any provider.

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