Coding and Reimbursement for Essure®
Essure procedure and confirmation test coding
Accurate diagnosis, procedure, and product coding are essential to help ensure prompt Essure claims processing and reimbursement. Coding for Essure can include CPT codes, HCPCS codes, ICD-10 codes, and modifiers, and may include no-cost coverage.
Current Procedural Terminology (CPT®) Fourth Edition* codes
The following CPT Fourth Edition codes may be used to report procedures associated with Essure:
|Essure procedure||58565||Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants|
|Modified HSG||58340||Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or HSG|
|Modified HSG, interpretation and supervision||74740||HSG, radiologic supervision and interpretation|
|Modified HSG, interpretation||74740-26||HSG, radiologic supervision and interpretation, professional component only|
|Modified HSG, supervision||74740-TC||HSG, radiologic supervision and interpretation, technical component only|
*CPT codes, descriptions, and other data are copyright 2010 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Healthcare Common Procedural Coding System (HCPCS) code
The following HCPCS code may be used in addition to the CPT code for selected payers that, including some state Medicaid† programs, allow for separate payment. Please check with the payer to confirm whether payment is separate or bundled.
|Essure procedure||A4264||Permanent implantable contraceptive intratubal occlusion device(s) and delivery system|
†Please note that Medicare does not allow for separate reporting and billing of permanent implantable contraception. Private payers and Medicaid will make their own determination on whether or not to use the HCPCS code. Please confirm with your payer that A4264 is allowed for billing and will be paid.
ICD-10 CM Diagnosis codes
For many payers, the following codes from the International Classification of Diseases, 10th edition, may be used to identify the Essure Confirmation Test with modified HSG/TVU as a preventive service:
|Essure procedure||Z30.2||Encounter for sterilization|
|Essure Confirmation Test||Z98.51||Tubal ligation status|
|Essure Confirmation Test (identified as a preventive service)||Z30.8||Other specified contraceptive management|
|Essure Confirmation Test||Z30.49||Surveillance of other contraceptive management|
CPT Modifier 33 is applicable for the identification of preventive services without cost sharing‡ and may be added to the following CPT codes:
|Essure procedure||58565-33||Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants|
|Modified HSG||58340-33||Catheterization and introduction of saline or contrast material for SIS or HSG|
‡Not all commercial payers will require the use of Modifier 33. Some will automatically process Essure and the Essure Confirmation Test without patient cost sharing.
Pursuant to the Affordable Care Act (ACA), the Essure Confirmation Test with TVU or modified HSG may be available to most patients at no cost
Many payers may cover both Essure and the Essure Confirmation Test with TVU or modified HSG if the patient is eligible under their plan. When verifying patient benefits, it is important to specifically ask whether the Essure Hysteroscopic Sterilization Procedure (CPT 58565 and/or A4264§) and the Essure Confirmation Test with modified HSG (CPT 58340 and CPT 74740) are covered at NO COST SHARE to the patient as part of preventive services. Inquire about limitations and exemptions under the Affordable Care Act (ACA).
Although many insurers must comply with this legislation, some plans have limitations or are exempt due to religious affiliation or grandfathered status.
For more information, call our reimbursement hotline at 1-877-ESSURE2 and press "#".
Multiple necessary services are performed by a healthcare provider during a procedure. These services are said to be billed/paid "globally"—sometimes referred to as the global/surgical package. The global/surgical package also includes a global period: a set number of days during the postoperative period. The global period is usually 90 days for major procedures and 0 to 10 days for minor procedures. Therefore, all follow-up care, including the treatment of complications, is included in the global period and cannot be billed separately.
Because the Essure Instructions for Use states than an Essure Confirmation Test with TVU/modified HSG is a required part of the Essure procedure, it is considered typical and usual, and will not be paid separately if it is performed within the 90-day global period of the Essure procedure.
Although this information should help make filing claims easier and help reduce claim rejection, its use does not guarantee payment. It is important to research coverage and payment for each patient since policies and guidelines vary by payer and plan. You are responsible for submitting accurate, complete and appropriate claims to payers, and for compliance with any obligations you may have as required by law, contract, or otherwise.