ModifiedAlliance HealthPolicy 1E-3

Sterilization Procedures

Defines coverage, eligibility, and requirements for sterilization procedures (tubal sterilization, opportunistic salpingectomy, vasectomy) for North Carolina Medicaid beneficiaries; includes EPSDT and undocumented alien provisions and policy-level requirements for providers.

Policy Summary

PayerAlliance Health

PolicySterilization Procedures

Policy CodePolicy 1E-3

Change TypeMaterial changes: BRCA exception, signature clarification, terminology update, consent-on-file requirement

Effective Date

Next Review Date

Key ActionObtain and retain a completed federal sterilization consent form (with required NPIs and legible signatures or printed full name) and ensure it is on file with the DHHS fiscal contractor before submitting claims.

SourceLink

POLICY UPDATE CHANGES

A Consent for Sterilization Form is not required when a beneficiary tests positive for BRCA1 or BRCA2 and requires a risk-reduction salpingo-oophorectomy.

All handwritten signatures must be legible, or the full (first and last) name must be printed below the handwritten signature; initials or abbreviations restrictions were removed in a prior revision.

Changed terminology from 'prophylactic bilateral salpingectomy' to 'opportunistic salpingectomy' and updated related definitions and requirements.

A valid sterilization consent must be on file with DHHS fiscal contractor before payment can be made for a sterilization procedure.

30-180 daysconsent window

>=21minimum consent age

Not eligibleUndocumented aliens

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NC onlyApplicable state

BRCA+ coveredBRCA exception

Coverage Criteria and Eligibility

General Coverage (Adults)

Covered when ALL of the following are met

Standard adult coverage: Beneficiary is enrolled in NC Medicaid and age 21 or older; sterilization procedure meets 42 CFR Part 441 Subpart F and this policy's requirementsage >= 21

Provider must verify eligibility at each service and consider service restrictions

EPSDT Exception (Beneficiaries under 21)

Covered for beneficiaries under 21 when ALL EPSDT conditions are met

EPSDT exception: Provider documents medical necessity showing the service corrects or ameliorates a defect, illness, or condition per EPSDT; service is not unsafe, ineffective, or experimentalbeneficiary < 21 meets EPSDT medical necessity

If prior approval is required by policy, EPSDT does not eliminate that requirement

Covered procedures

Covered when ALL of the following are met

General medical necessity: Procedure/product/service is individualized, specific, consistent with symptoms or confirmed diagnosis, not in excess of beneficiary's needs, can be safely furnished, and no equally effective and more conservative or less costly statewide treatment is available; not primarily for convenience.

From Section 3.1

Voluntary sterilization specific criteria: Informed consent is signed; beneficiary is not legally declared mentally incompetent; beneficiary is not involuntarily confined/detained under civil or criminal statute in correctional/rehabilitative/mental facilities or confined under voluntary commitment in such facilities; informed consent was given.

From Section 3.2.2(a)

Opportunistic salpingectomy for BRCA: Opportunistic salpingectomy is covered when beneficiary meets requirements in section 3.2.2(a) and has tested positive for BRCA1 or BRCA2.BRCA1 or BRCA2 positive

General coverage and consent criteria

Sterilization procedures are covered when ALL of the following are met:

consent_on_file: A valid sterilization consent form is completed and on file with the DHHS fiscal contractor before payment can be made for a sterilization procedure.

Consent form is federally mandated and must follow Attachment B instructions

signatures: Handwritten signatures are required for beneficiary, person obtaining consent, interpreter (if used), and physician; signatures must be legible or the full first and last name printed below the signature; digital signatures or stamps are not acceptable; physician's signature date must be on or after the date of service.

Illegible signatures allowed if full name printed below per 02/15/2023 revision

interpreter_documentation: Interpreter's handwritten signature, date, and language must be documented; telephone interpreters must submit attestation matching consent wording and must be attached; the provider obtaining consent must retain the original consent form and provide copies to beneficiary and performing provider.

Attestation must be attached to consent and original retained in health record

Form content, identifiers, and operative record requirements

Additional required elements for a valid consent form

Form completion and signatures: All required fields on the federal sterilization consent form must be completed (person/facility providing information, beneficiary name and DOB matching records, physician name); beneficiary, person obtaining consent, interpreter (if used), and physician must provide handwritten, legible signatures dated; digital signatures or signature stamps are not acceptable; if initials are used or signature illegible, print full name below the signature.

Fields in bold on the federal form cannot be altered; errors in those areas may prevent re-submission

Identifiers and NPIs: Surgeon's NPI must be added to the top left margin, beneficiary identification number to the top right margin, and facility NPI to the top center of the consent form; facility NPI must be populated on initial submission so the facility can make inquiries regarding consent status.

Required identifiers must be present for processing by DHHS fiscal contractor

Operative record exceptions: If the date of surgery is changed on the consent form, or in cases of emergency abdominal surgery or preterm delivery where sterilization is performed less than 30 days after signature, operative records or the physician's alternate paragraph must be submitted to verify date of service or circumstances.

BRCA-positive beneficiaries

Exception:

BRCA_exception: A Consent for Sterilization form is not required when a beneficiary tests positive for BRCA1 or BRCA2 and requires a risk-reduction salpingo-oophorectomy; when opportunistic salpingectomy is performed for BRCA-positive beneficiaries, claims must be billed with diagnosis code Z15.01, Z15.02, or Z15.04.

Policy change: consent form exception for BRCA-positive risk-reduction surgery

Coverage conditions

Covered when documentation and billing meet federal and state requirements

Consent and documentation: A valid sterilization consent form must be on file; associated services following sterilization will be denied or recouped if the consent form on file is invalid; if a claim is denied for additional information, resubmit as an adjustment with the requested documents and a copy of the valid consent form attached.

Claims denied for additional information must be resubmitted with documents and consent

Coding requirements: All claims must include ICD-10-CM code Z30.2 as the primary or secondary diagnosis on the claim; when opportunistic salpingectomy is performed for BRCA1 or BRCA2 positive beneficiaries, use diagnosis code Z15.01, Z15.02, or Z15.04.

From ICD-10-CM coding guidance

Modifier and billing format: Append modifier FP to the procedure code for sterilization procedures for all providers except ambulatory surgical centers; institutional claims must follow UB-04 guidelines including placing non-covered charges in the Non-Covered column and uploading a printed UB when required.

Modifier FP required except for ASCs; follow NCTracks/UB-04 submission instructions

Consent timing and age requirements

Covered when ALL of the following are met

Consent timing and age: Beneficiary is at least 21 years old at time consent is signed; the date of the beneficiary's signature must be at least 30 consecutive days and no more than 180 consecutive days prior to the date of sterilization (count begins the day after signature).age >= 21; 30 <= days_between_signature_and_procedure <= 180

Exceptions for premature delivery or emergency abdominal surgery allow sterilization performed less than 30 days but more than 72 hours after signature with documentation and use of the alternate physician paragraph

Undocumented aliens are eligible for Medicaid emergency services only and sterilization procedures are not considered emergency services. Therefore, undocumented aliens are not eligible for sterilization procedures and claims for sterilization for this population may be denied.

Undocumented aliens are eligible solely for Medicaid emergency services and sterilization is not considered an emergency service; as a result, sterilization is not covered for undocumented aliens. The policy also specifies that sterilization is not covered when requirements in section 3.2.2 are not met and that certain hysteroscopic/transcervical sterilization devices and procedures (e.g., Essure) are excluded.

Hysteroscopic tubal sterilization and related procedures (including the Essure system) are no longer covered by NC Medicaid; historical policy edits removed Essure and associated CPT codes from this clinical coverage policy. Providers should not bill NC Medicaid for Essure or hysteroscopic tubal occlusion procedures.

If a valid federal sterilization consent form is not available or the beneficiary is within a population group for whom the state cannot provide sterilization, the sterilization charges must be billed as non-covered. Submit the claim placing non-covered charges in the Non-Covered column, upload a printed UB with the electronic submission, and do not include a sterilization diagnosis or ICD-10 procedure code on the claim.

When a valid consent form is not on file or the state cannot provide sterilization for a beneficiary, the sterilization must be billed as non-covered charges. The provider must place non-covered charges in the Non-Covered column on the claim, upload a printed UB noting the change in the Remarks field, and omit any sterilization diagnosis or ICD-10 procedure code from the claim.

Sterilization is not covered when the beneficiary does not meet the eligibility requirements in Section 2.0 or the clinical criteria in Section 3.0, when the service duplicates another provider's procedure, or when the procedure is experimental or part of a clinical trial. Additionally, specific exclusions apply (for example, Essure and certain bilateral occlusion systems), and sterilization reversal procedures are not covered.

Dilation and curettage (D&C) performed on the same date of service as a sterilization procedure is subject to suspension for medical review; health records may be requested to support the claim.

When opportunistic salpingectomy is performed for beneficiaries who test positive for BRCA1 or BRCA2, claims must include the appropriate BRCA-related diagnosis codes. The policy lists the applicable ICD-10 diagnosis codes for this indication (see coding table).

Coding and Billing Requirements

ICD-10 procedure codes referenced in historyICD-10

0UB70ZZ	ICD-10-PCS code added previously (listed in history)
0UB73ZZ	ICD-10-PCS code added previously (listed in history)
0UB74ZZ	ICD-10-PCS code added previously (listed in history)
0UB77ZZ	ICD-10-PCS code added previously (listed in history)
0UB78ZZ	ICD-10-PCS code added previously (listed in history)

Open ProceduresCPT

58600	58600
58605	58605
58611	58611
58615	58615
58700	58700

Laparoscopic ProceduresCPT

58661	58661
58670	58670
58671	58671

Vasectomy ProceduresCPT

55250

ICD-10-PCS Codes (sample list)ICD-10

0U570ZZ	0U570ZZ
0U573ZZ	0U573ZZ
0U574ZZ	0U574ZZ
0U577ZZ	0U577ZZ
0U578ZZ	0U578ZZ
0UB70ZZ	0UB70ZZ
0UB73ZZ	0UB73ZZ
0UB74ZZ	0UB74ZZ
0UB77ZZ	0UB77ZZ
0UB78ZZ	0UB78ZZ

Diagnosis CodesICD-10

Z30.2	Encounter for sterilization
Z15.01	Genetic susceptibility to malignant neoplasm of ovary (BRCA1)
Z15.02	Genetic susceptibility to malignant neoplasm of ovary (BRCA2)
Z15.04	Genetic susceptibility to other malignant neoplasm

Acceptable abbreviations/descriptions for type of sterilizationmixed

OS	Opportunistic salpingectomy
BPS	Bilateral Partial salpingectomy
BTF	Bilateral tubal fulguration
BTS	Bilateral tubal sterilization
BTC	Bilateral tubal cauterization
BTL	Bilateral tubal ligation
BPPS	Bialteral postpartum sterilization
PPBTL	Postpartum bilateral tubal ligation
LTC	Laparoscopic tubal cautery

Consent timing

Consent timing windowConsent must be obtained at least 30 and not more than 180 consecutive days prior to the date of sterilization (count begins the day after signature).

Preterm delivery exceptionIf delivery is preterm (before 37 weeks), informed consent must have been given at least 30 consecutive days before the expected date of delivery (EDD) and at least 72 hours must have passed since consent was given.

Emergency abdominal surgery exceptionFor emergency abdominal surgery, at least 72 hours must have passed since informed consent was given.

Minimum age for consent

Minimum age for federal participation

Provider Responsibilities, Prior Authorization, and Claims

Denial Risk

Eligibility Verification and Denial Risk

Providers must verify each Medicaid beneficiary's eligibility at every service. An eligible beneficiary must be enrolled in NC Medicaid; service restrictions based on eligibility category may make a beneficiary ineligible for sterilization. Claims may be denied when the beneficiary does not meet eligibility (Section 2.0) or does not meet criteria in Section 3.0.

Verify beneficiary enrollment in NC Medicaid at each service
Claims may be denied when beneficiary does not meet Section 2.0 eligibility or Section 3.0 criteria

Documentation Required

Retention and Copies of Sterilization Consent Form

A valid completed federal sterilization consent form must be obtained prior to performing the procedure. The provider obtaining consent shall maintain the original completed consent form in the beneficiary's health record, provide a copy to the beneficiary, and retain copies as required (physician/provider conducting the procedure, interpreter if used, any other state agency/program requiring documentation). A copy must be retained at the service site where consent is obtained.

Definitions and Background

Sterilization is any procedure intended to render an individual permanently incapable of reproducing. Tubal sterilization (female) prevents pregnancy by interrupting fallopian tube function through methods such as clipping, cutting and tying, cauterization, or removal; approaches include minilaparotomy, laparoscopy, or as part of abdominal surgery. Vasectomy involves division or resection of the vas deferens. Opportunistic salpingectomy is removal of the fallopian tubes to reduce ovarian cancer risk and may be performed with other abdominal surgery.

Sterilization — definition

Sterilization definitionAny medical procedure, treatment, or operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to repair of a damaged or dysfunctional body part.

PurposeIntended to be permanent and to prevent future reproduction.

Exclusion from repair proceduresDoes not include procedures performed to repair a damaged or dysfunctional body part.

Tubal sterilization — definition

Policy Summary

PayerAlliance Health

PolicySterilization Procedures

Policy CodePolicy 1E-3

Change TypeMaterial changes: BRCA exception, signature clarification, terminology update, consent-on-file requirement

Effective Date

Next Review Date

SourceLink

On This Page

From Section 3.2.2(b)

billing_identifiers: The consent form must include the physician NPI (top left margin), facility NPI (top center), and beneficiary identification number (top right margin) for the form to be processed.

These identifiers are required to process the consent with DHHS fiscal contractor

Operative records required when dates are changed or for emergency/preterm delivery exceptions

Beneficiary must be at least 21 years old at the time consent is obtained for federal financial participation.

EPSDT noteEPSDT may allow coverage exceptions for beneficiaries under 21 when medically necessary, but the 21-year minimum for federal financial participation still applies for consent.

Verification requirementProviders must verify beneficiary age and eligibility when obtaining consent.

Primary diagnosis requirement

Required diagnosis codeAll claims must be billed with ICD-10-CM diagnosis code Z30.2 ('Encounter for sterilization') as the primary or secondary diagnosis code on the claim.

BRCA-related opportunistic salpingectomyWhen opportunistic salpingectomy is performed for a beneficiary who tested positive for BRCA1 or BRCA2, claims must be billed with diagnosis code Z15.01, Z15.02, or Z15.04.

Coding specificityProviders shall report ICD-10-CM to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at time of service.

Original consent form maintained in beneficiary health record by provider obtaining consent
Copy provided to beneficiary and other required parties
Copy retained at service site

Billing Rule

Required Identifiers on Consent Form

The sterilization consent form must include required identifiers to be processed: add the performing physician's valid NPI to the top left margin, the facility NPI where the procedure was performed to the top center, and the beneficiary identification number to the top right margin. A valid consent form must be on file with the DHHS fiscal contractor before payment can be made.

Physician NPI — top left margin
Facility NPI (procedure facility) — top center
Beneficiary identification number — top right margin
Consent must be filed with DHHS fiscal contractor before payment

Denial Risk

Claims Submission, Denials, and Non-Covered Billing

When the sterilization consent form on file is invalid or missing, all associated services following sterilization will be denied or recouped. If a claim is denied requesting additional information (including health records or consent), resubmit the claim as an adjustment with the requested documents and attach a copy of a valid consent form. If a valid consent is not available or the beneficiary is in a population group for whom the state cannot provide sterilization (e.g., undocumented aliens), submit the claim as non-covered with supporting documentation as specified below.

Invalid or missing consent = denial or recoupment of associated services
Claims denied for additional information must be resubmitted as an adjustment with requested documents and a copy of a valid consent
When valid consent is not available or state cannot provide sterilization: place sterilization charges in the Non-Covered column, upload printed UB claim, note non-covered change in UB Remarks field, and do not include a sterilization diagnosis or ICD-10 procedure code on the claim
Undocumented aliens are eligible for emergency services only and are not eligible for sterilization

Prior Authorization

Prior Authorization and EPSDT

EPSDT does not eliminate prior approval requirements when a prior approval is specified by policy. However, Medicaid does not require prior approval for sterilization procedures under this policy.

If prior approval is required by a policy, EPSDT does not waive that requirement for beneficiaries under 21
Medicaid policy: prior approval is not required for sterilization procedures

Note

Procedural Appropriateness and Lifetime Limit

Procedures must be individualized, consistent with diagnosis/symptoms, not in excess of needs, safe, and provided only when no equally effective, more conservative, or less costly statewide alternative exists. Sterilization is covered once in a lifetime unless documentation supports a repeat due to a failed procedure.

Procedural appropriateness must be documented
Lifetime limit: sterilization covered once unless repeat documented due to failure

Tubal sterilization definitionFemale sterilization (tubal occlusion or ligation) is a permanent contraceptive method that prevents egg transport by blocking the fallopian tubes via clipping, cutting and tying, or cauterization; performed via minilaparotomy, laparoscopy, or other approaches.

Approaches and anesthesiaMay be performed under local anesthesia with light sedation (minilaparotomy) or under general anesthesia (laparoscopy).

Surgical sitesIncisions can be made in the abdomen above the pubic hair, at the belly button and lower abdomen, or in the back wall of the vagina.

Opportunistic salpingectomy — definition

Opportunistic salpingectomy definitionSurgical removal of the fallopian tube(s) to reduce the risk of ovarian cancer; may be performed alone or in conjunction with other abdominal surgery such as hysterectomy.

Policy name updateTerm updated from 'prophylactic bilateral salpingectomy' to 'opportunistic salpingectomy' to align with CMS language.

BRCA-related coverageOpportunistic salpingectomy is covered when beneficiary meets requirements in section 3.2.2(A) and has tested positive for BRCA1 or BRCA2.

Vasectomy — definition

Vasectomy definitionSurgical division or resection of all or part of the vas deferens to induce sterility.

PurposeIntended as a permanent contraceptive method for male beneficiaries.

Procedure variabilityMay involve division or resection of vas deferens segments; coding and documentation should reflect performed technique.

Preterm delivery — definition

Preterm delivery definitionDelivery that occurs at less than 37 weeks gestation.

Consent timing implicationPreterm delivery modifies the standard consent timing rules: informed consent must have been given at least 30 consecutive days before the EDD and at least 72 hours must have passed since consent was given.

Use in exceptionsReferenced as an exception to the 30- to 180-day consent timing requirement.

Opportunistic salpingectomy — BRCA-related coverage

BRCA-related opportunistic salpingectomy policyOpportunistic salpingectomy is covered when the beneficiary meets all requirements in section 3.2.2(A) and has tested positive for BRCA1 or BRCA2; when performed for BRCA+ beneficiaries, claims must be billed with diagnosis code Z15.01, Z15.02, or Z15.04.

Consent form exemptionA Consent for Sterilization Form is not required when a beneficiary tests positive for BRCA1 or BRCA2 and requires a risk-reduction salpingo-oophorectomy.

Documentation requirementCoverage is contingent on meeting the policy's 3.2.2(A) criteria in addition to positive BRCA status.

Sterilization reversal — definition and non-coverage

Sterilization reversal non-coverageMedicaid shall not cover procedures for the reversal of sterilization (e.g., bilateral salpingoplasty or bilateral vasovasostomy).

Examples of reversal proceduresReversal procedures include reverse bilateral fallopian tube transection by bilateral salpingoplasty and reversal of bilateral vasectomy by vasovasostomy.

Billing implicationSterilization reversal procedures are explicitly excluded from coverage and should not be billed as covered services.

Opportunistic Salpingectomy — terminology update

Terminology updatePolicy terminology updated: 'prophylactic bilateral salpingectomy' replaced with 'opportunistic salpingectomy' to align with CMS language.

Definition alignmentRelated definitions and requirements were updated in the policy history to reflect the naming change and clarify intent.

Historical noteChange recorded in policy history (02/15/2023) where the term change and definition updates are documented.