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,  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     

07/01/2024 Annual review, no change to policy intent.
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.

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