59325
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.96
Facility
$215.44
Non-Facility
$215.44
Documentation Required
- When billing, include the appropriate covered ICD-10 diagnosis code(s): N88.3; O34.30-O34.33; O34.40-O34.43 (as applicable) to support the indication.
- Use of covered diagnosis and procedure codes corresponding to the covered indications (covered CPT codes when selection criteria are met: 57700; 59325; covered ICD-10 codes: N88.3; O34.30 - O34.33; O34.40 - O34.43).
- Evidence in the medical record that a transvaginal cerclage was not possible or has previously failed when that is the basis for transabdominal approach (implicit in listed indications and requirement to document history consistent with incompetent cervix).
- Documented history consistent with incompetent cervix, including a history of mid-trimester pregnancy loss associated with painless cervical dilatation without evidence of uterine activity, to establish medical necessity.
Key Coverage Criteria
- CPT codes covered if selection criteria are met: 59325 (Cerclage of cervix, during pregnancy; abdominal)
- ICD-10 codes covered if selection criteria are met: N88.3 (Incompetence of cervix uteri)
- ICD-10 codes covered if selection criteria are met: O34.30 - O34.33 (Maternal care for cervical incompetence)
- ICD-10 codes covered if selection criteria are met: O34.40 - O34.43 (Maternal care for other abnormalities of cervix [shortened, amputated, or deep traumatized cervix])
- Deep traumatized cervix
- Previous failed cervical (transvaginal) cerclages
2 Active Policies
AETNA-CPB-0529 — Transabdominal Cerclage
CIGNA-0284 — Recurrent Pregnancy Loss: Diagnosis and Treatment - (0284)
Related Codes
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