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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 : Facility Fees for Sterilization
Hospital-based and freestanding ambulatory surgical centers (HASCs/ASCs) may be reimbursed for procedure code 55250, 58260, 58262, 58565, 58600, 58615, 58670, or 58671. An appropriate family planning diagnosis code must be billed when reporting facility fees for procedure codes 58565 or 58670.
Refer to:
Ambulatory Surgical Center on the TMHP website at for a claim form example.
Subsection 5.2.14, “Gynecological and Reproductive Health and Family Planning Services” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional gynecological, reproductive health, and family planning services procedure codes that may be reimbursed to ASC and HASC providers.

Texas Medicaid & Healthcare Partnership
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