Contraceptive Management - CAM 017
Indications and Limitations of Coverage:
Contraceptive management refers to the use of contraceptive devices, implants, medications, injections and related services (e.g., insertion/removal of an implant or IUD) for the prevention of pregnancy (i.e., birth control). Contraceptive management is determined according to a specific individual or group benefits.
Description:
Contraceptive management refers to the use of contraceptive devices, implants, medications, injections and related services (i.e., insertion/removal of an implant or IUD) for the prevention of pregnancy (i.e., birth control).
Related Policies:
094 Women's Preventive Services
Policy:
Reimbursement is allowed under the following when there is a SPECIFIC individual or group benefit for contraceptive management:
-
Medications/drugs will be considered for allowance under the pharmacy benefits.
-
Implantation and removal of devices/implants will be considered for allowance under the medical benefits.
PLEASE SEE SPECIFIC CONTRACT VERBIAGE FOR BENEFITS, LIMITATIONS AND/OR EXCLUSIONS OF CONTRACEPTIVE MANAGEMENT.
Coding Section
| Codes | Number | Description |
| CPT | 11976 | Removal, implantable contraceptive capsules |
| 11980 | Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) | |
| 11981 | Insertion, non-biodegradable drug delivery implant (e.g., Implanon) | |
| 11982 | Removal, non-biodegradable drug delivery implant | |
| 11983 | Removal with reinsertion, non-biodegradable drug delivery implant | |
| 55250 | VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S) | |
| 57170 | Diaphragm or cervical cap fitting with instructions | |
| 58300 | Insertion of intrauterine device (IUD) | |
| 58301 | Removal of intrauterine device (IUD) | |
| 58340 | CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY **** could be performed as a follow up for Essure. | |
| 58565 | Hysteroscopy, surgical, with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants | |
| 58600 | Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral | |
| 58605 | Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, Unilateral or bilateral, during same hospitalization | |
| 58611 | Ligation or transection of fallopian tube(s) when done at time of cesarean or Intra-abdominal surgery | |
| 58615 | Occlusion of fallopian tube(s), by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach | |
| 58670 | LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION) | |
| 58671 | Laparoscopy, surgical, with occlusion of oviducts by device (e.g., band, clip, or Falope ring) | |
| 58700 | Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) | |
| 74740 | HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ****could be performed after Essure | |
| 96372 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug), subcutaneous or Intramuscular (e.g., Lunelle) | |
| ICD-9 Diagnosis | V15.7 | PERSONAL HISTORY OF CONTRACEPTION, PRESENTING HAZARDS TO HEALTH |
| V25.01 | Prescription of oral contraceptives | |
| V25.02 | Initiation of other contraceptive measures. | |
| V25.03 | Encounter for emergency contraceptive counseling and prescription. | |
| V25.04 | Counseling and instruction in natural family planning to avoid pregnancy | |
| V25.09 | Other family planning advice | |
| V25.11 | Other family planning advice | |
| V25.12 | Encounter for insertion of intrauterine contraceptive device | |
| V25.13 | Encounter for removal and reinsertion of intrauterine contraceptive device. | |
| V25.2 | Sterilization | |
| V25.40 | CONTRACEPTIVE SURVEILLANCE, UNSPECIFIED | |
| V25.41 | Contraceptive pill | |
| V25.42 | Intrauterine contraceptive device | |
| V25.43 | Implantable subdermal contraceptive |
|
| V25.49 | Other contraceptive method | |
| V25.59 | Insertion of implantable subdermal contraceptive | |
| V25.8 | OTHER SPECIFIED CONTRACEPTIVE MANAGEMENT | |
| V25.9 | UNSPECIFIED CONTRACEPTIVE MANAGEMENT |
|
| V26.41 | PROCREATIVE COUNSELING AND ADVICE USING NATURAL FAMILY PLANNING | |
| V26.49 | OTHER PROCREATIVE MANAGEMENT COUNSELING AND ADVICE | |
| V26.49 | OTHER PROCREATIVE MANAGEMENT COUNSELING AND ADVICE | |
| V26.51 | TUBAL LIGATION STATUS | |
| V26.52 | VASECTOMY STATUS | |
| V26.89 | OTHER SPECIFIED PROCREATIVE MANAGEMENT | |
| V26.9 | UNSPECIFIED PROCREATIVE MANAGEMENT |
|
| V45.51 | PRESENCE OF INTRAUTERINE CONTRACEPTIVE DEVICE | |
| V45.52 | PRESENCE OF SUBDERMAL CONTRACEPTIVE IMPLANT | |
| V45.59 | PRESENCE OF OTHER CONTRACEPTIVE DEVICE | |
| 996.32 | Mechanical complication due to intrauterine contraceptive device | |
| ICD-9 Procedure | 63.7 | MALE STERILIZATION PROCEDURE, NOT OTHERWISE SPECIFIED |
| 63.72 | LIGATION OF SPERMATIC CORD | |
| 63.73 | VASECTOMY | |
| 66.21 | BILATERAL ENDOSCOPIC LIGATION AND CRUSHING OF FALLOPIAN TUBES | |
| 66.22 | BILATERAL ENDOSCOPIC LIGATION AND DIVISION OF FALLOPIAN TUBES | |
| 66.29 | OTHER BILATERAL ENDOSCOPIC DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES | |
| 66.31 | OTHER BILATERAL LIGATION AND CRUSHING OF FALLOPIAN TUBES | |
| 66.32 | OTHER BILATERAL LIGATION AND DIVISION OF FALLOPIAN TUBES | |
| 66.39 | OTHER BILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES | |
| 66.51 | REMOVAL OF BOTH FALLOPIAN TUBES AT SAME OPERATIVE EPISODE | |
| 66.52 | REMOVAL OF REMAINING FALLOPIAN TUBE | |
| 66.92 | UNILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBE | |
| 66.99 | OTHER OPERATIONS ON FALLOPIAN TUBES | |
| 69.7 | INSERTION OF INTRAUTERINE CONTRACEPTIVE DEVICE | |
| 87.85 | OTHER X-RAY OF FALLOPIAN TUBES AND UTERUS | |
| 97.71 | REMOVAL OF INTRAUTERINE CONTRACEPTIVE DEVICE | |
| HCPCS | A4261 | Cervical cap for contraceptive use |
| A4264 | Permanent implantable contraceptive intratubal occlusion device(s) and delivery system | |
| A4266 | DIAPHRAGM FOR CONTRACEPTIVE USE | |
| A4267 | CONTRACEPTIVE SUPPLY, CONDOM, MALE, EACH | |
| A4268 | CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACH | |
| A4269 | CONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACH |
|
| J1050 | Medroxyprogesterone acetate, 1 mg |
|
| J7296 | Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg | |
| J7297 | Levonorgestrel-releasing intrauterine contraceptive system, 52mg, 3 year duration (Liletta) | |
| J7298 | Levonorgestrel-releasing intrauterine contraceptive system, 52mg, 5 year duration (Mirena) | |
| J7300 | Intrauterine copper contraceptive | |
| J7301 | Levonorgestrel-releasing intrauterine contraceptive system (Skyla),13.5mg |
|
| J7302 | Levonorgestrel-releasing intrauterine contraceptive system (e.g., Mirena) | |
| J7303 | Contraceptive supply, hormone containing vaginal ring, each | |
| J7304 | Contraceptive supply, hormone containing patch, each | |
| J7306 | Levonorgestrel (contraceptive) implant system, including implants and supplies | |
| J7307 | Etonogestrel (contraceptive) implant system, including implant and supplies | |
| Q9984 | Kyleena™ (levonorgestrel-releasing intrauterine system) 19.5 mg | |
| S4981 | Insertion of levonorgestrel-releasing intrauterine system (e.g., Mirena) | |
| S4989 | Contraceptive intrauterine device (e.g., Progestasert IUD) | |
| S4993 | CONTRACEPTIVE PILLS FOR BIRTH CONTROL | |
| ICD-10-CM (effective 10/01/15) | Z92.0 | Personal history of contraception |
| Z30.011 | Encounter for initial prescription of contraceptive pills | |
| Z30.018 | Encounter for initial prescription of other contraceptives | |
| Z30.012 | Encounter for prescription of emergency contraception | |
| Z30.02 | Counseling and instruction in natural family planning to avoid pregnancy | |
| Z30.09 | Encounter for other general counseling and advice on contraception | |
| Z30.430 | Encounter for insertion of intrauterine contraceptive device | |
| Z30.432 | Encounter for removal of intrauterine contraceptive device | |
| Z30.433 | Encounter for removal and reinsertion of intrauterine contraceptive device | |
| Z30.2 | Encounter for sterilization | |
| Z30.40 | Encounter for surveillance of contraceptives, unspecified | |
| Z30.41 | Encounter for surveillance of contraceptive pills | |
| Z30.431 | Encounter for routine checking of intrauterine contraceptive device | |
| Z30.49 | Encounter for surveillance of other contraceptives | |
| Z30.8 | Encounter for other contraceptive management | |
| Z30.9 | Encounter for contraceptive management, unspecified | |
| Z31.61 | Procreative counseling and advice using natural family planning | |
| Z31.69 | Encounter for other general counseling and advice on procreation | |
| Z98.51 | Tubal ligation status | |
| Z98.52 | Vasectomy status | |
| Z31.89 | Encounter for other procreative management | |
| Z31.9 | Encounter for procreative management, unspecified | |
| Z97.5 | Presence of (intrauterine) contraceptive device | |
| T83.39XA | Other mechanical complication of intrauterine contraceptive device, initial encounter | |
| ICD-10-PCS (effective 10/01/15) | 0V5N0ZZ-0V5N4ZZ; 0V5P0ZZ-0V5P4ZZ; 0V5Q0ZZ-0V5Q4ZZ; 0VBN0ZZ-0VBN4ZZ; 0VBP0ZZ-0VBP4ZZ; 0VBQ0ZZ-0VBQ4ZZ; 0VTN0ZZ-0VTN4ZZ; 0VTP0ZZ-0VTP4ZZ; 0VTQ0ZZ-0VTQ4ZZ |
Male sterilization procedure code range |
| 0VLF0CZ; 0VLF0DZ; 0VLF0ZZ; 0VLF3CZ; 0VLF3DZ; 0VLF3ZZ; 0VLF4CZ; 0VLF4DZ; 0VLF4ZZ; 0VLG0CZ; 0VLG0DZ; 0VLG0ZZ; 0VLG3CZ; 0VLG3DZ; 0VLG3ZZ; 0VLG4CZ; 0VLG4DZ; 0VLG4ZZ; 0VLH0CZ; 0VLH0DZ; 0VLH0ZZ; 0VLH3CZ; 0VLH3DZ; 0VLH3ZZ; 0VLH4CZ; 0VLH4DZ; 0VLH4ZZ | Ligation of spermatic cord code range | |
| 0VBN0ZZ-0VBN4ZZ; 0VBP0ZZ-0VBP4ZZ; 0VBQ0ZZ-0VBQ4ZZ; 0VTB0ZZ-0VTN4ZZ; 0VTP0ZZ-0VTP4ZZ; 0VTQ0ZZ-0VTQ4ZZ | Vasectomy code range | |
| 0UL74ZZ; 0UL78ZZ | Occlusion of Bilateral Fallopian Tubes code range | |
| 0U574ZZ-0U578ZZ; 0UL74CA; 0UL74DZ; 0UL74ZZ; 0UL78DZ; 0UL78ZZ | Destruction or Occlusion of Bilateral Fallopian Tubes code range | |
| 0UL70ZZ; 0UL73ZZ; 0UL77ZZ | Other bilateral ligation and crushing of fallopian tubes code range | |
| 0U570ZZ-0U573ZZ; 0U577ZZ; 0UL70CZ; 0UL70DZ; 0UL70ZZ; 0UL73CZ; OUL73CZ; 0UL73DZ; 0UL73ZZ; 0UL77DZ; OUL77ZZ | Other bilateral destruction or oclusion of fallopian tubes codes range | |
| 0UT70ZZ; 0UT74ZZ; 0UT77ZZ; 0UT78ZZ; 0UT7FZZ | Removal of both fallpian tubes at same operative espisode code range | |
| 0UT50ZZ-0UT58ZZ; 0UT5FZZ; 0UT60ZZ-0UT68ZZ; OUT6FZZ | Removal of remaining fallopian tube code range | |
| 0U550ZZ-0U558ZZ; 0U560ZZ-0U568ZZ; 0UL50CZ; 0UL53DZ; 0UL53ZZ; 0UL54CZ; 0UL54DZ; 0UL54ZZ; 0UL57DZ; 0UL57ZZ; 0UL58DZ; 0UL58ZZ; 0UL60CZ; 0UL60DZ; 0UL60ZZ; 0UL63CZ; 0UL63DZ; 0UL63ZZ; 0UL64CZ; 0UL64DZ; 0UL64ZZ; 0UL67DZ; 0UL67ZZ; 0UL68DZ; 0UL68ZZ | Unilateral destruction or occlusion of fallopian tube code range | |
| 0UQ50ZZ; 0UQ53ZZ; 0UQ54ZZ; 0UQ57ZZ; 0UQ58ZZ; 0UQ60ZZ; 0UQ63ZZ; 0UQ64ZZ; 0UQ67ZZ; 0UQ68ZZ; 0UQ70ZZ; 0UQ73ZZ; 0UQ74ZZ; 0UQ77ZZ; 0UQ78ZZ | Other operations on fallopian tubes code range | |
| 0UH97HZ; 0UH98HZ; 0UHC7HZ; 0UHC8HZ | Insertion of Contraceptive Device code ragne | |
| BU000ZZ; BU001ZZ; BU00YZZ; BU010ZZ; BU011ZZ; BU020ZZ; BU021ZZ; BU060ZZ; BU061ZZ; BU080ZZ; BU081ZZ; BU100ZZ; BU101ZZ; BU10YZZ; BU10ZZZ; BU110ZZ; BU111ZZ; BU11YZZ; BU11ZZZ; BU120ZZ; BU121ZZ; BU12ZZZ; BU160ZZ; BU161ZZ; BU16ZZZ; BU180ZZ; BU181ZZ; BU18ZZZ | Other X-Ray of fallopian tubes and uters code range | |
| 0UPD7HZ; 0UPD8HZ | Removal of Contraceptive Device code range |
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.
"Current Procedural Terminology © American Medical Association. All Rights Reserved"
History From 2014 Forward
| 07/03/2023 | Annual review, no change to policy intent. |
| 07/06/2022 |
Annual review, no change to policy intent. |
| 07/13/2021 |
Annual review, no change to policy intent. |
| 07/20/2020 |
Corrected typo in history box. No change to policy intent. |
| 07/08/2020 |
Annual review, no change to policy intent. |
| 07/01/2019 |
Annual review, no change to policy intent. |
| 07/09/2018 |
Annual review, no change to policy intent. |
| 11/21/2017 |
Updated policy to add code J7296. No other changes. |
| 10/30/2017 |
Correcting Code Q8894 to Q9984. No other changes. |
| 10/09/2017 |
Added HCPCS code Q8894 to coding section. No other changes. |
| 07/03/2017 |
Annual review, no change to policy intent. |
| 07/18/2016 |
Annual review, no change to policy intent. Updating coding. |
| 07/07/2015 |
Annual review, no change to intent. Updated related policies, added coding. |
| 07/10/2014 |
Annual review. Added Related Policies. No change to policy intent. |