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016.06.63-IV. Facility Claims

AR ADC 016.06.63-IVArkansas Administrative Code

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 06. Division of Medical Services
Rule 63. Billing for Essure Procedure and Device
Ark. Admin. Code 016.06.63-IV
016.06.63-IV. Facility Claims
Currentness
Bill for hospital-based outpatient clinics, ambulatory surgical centers, and outpatient hospital claims using the following protocol:
A. Hospital-based outpatient clinics may bill for the Essure procedure and provision of the device as shown below.
Procedure Code
Modifier
Procedure Description
58565
U3
“Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-PROCEDURE ONLY”
58565
U2
“Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-DEVICE ONLY”
B. Ambulatory surgical centers and outpatient hospitals may bill for the Essure procedure and device following the protocol below:
Procedure Code
Modifier
Procedure Description
58565
U3
“Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-PROCEDURE ONLY”
58565
U1
“Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants-DEVICE ONLY”
All post-Essure coverage policy and billing protocols are unchanged. No other family planning services are changed. All other billing requirements must be met in order to be reimbursed for these services.
Thank you for your participation in the Arkansas Medicaid Program.
If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at 501-682-8323 (Local); 1-800-482-5850, extension 2-8323 (Toll-Free) or to obtain access to these numbers through voice relay, 1-800-877-8973 (TTY Hearing Impaired).
If you have questions regarding this notice, please contact the EDS Provider Assistance Center at In-State WATS 1-800-457-4454, or locally and Out-of-State at (501) 376-2211.
Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Credits

Adopted Nov. 26, 2009.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.06.63-IV, AR ADC 016.06.63-IV
End of Document