Find comprehensive information on tubal ligation diagnosis, including ICD-10 codes (Z30.2, Z30.4), CPT codes for sterilization procedures, postoperative diagnosis documentation, and clinical terminology related to female sterilization. Learn about bilateral tubal ligation, post-tubal ligation syndrome, and other related medical coding and healthcare documentation essentials for accurate clinical records. Explore resources for physicians, coders, and healthcare professionals seeking guidance on tubal ligation documentation and coding best practices.
Also known as
Encounters for contraceptive management
Codes for encounters related to contraception, including sterilization.
Encounter for sterilization
Encounters specifically for sterilization procedures.
Failed attempted sterilization
When a sterilization procedure, like tubal ligation, was unsuccessful.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the tubal ligation currently being performed?
Yes
Code Z30.2 Encounter for sterilization
No
Is the encounter for complications?
When to use each related code
| Description |
|---|
| Tubal ligation |
| Essure procedure |
| Salpingectomy |
Miscoding tubal ligation with Z30.2 (encounter for sterilization) instead of the appropriate procedure code (e.g., Z30.4 for laparoscopic).
Insufficient documentation of the tubal ligation procedure, including laterality (bilateral or unilateral), method, and any complications.
Incorrect billing for tubal ligation under Medicaid, particularly regarding informed consent requirements and mandatory waiting periods.
Patient presents for postoperative follow-up status post bilateral tubal ligation. Procedure performed on [Date] via [Surgical approach; e.g., laparoscopy, mini-laparotomy] for elective sterilization. Patient reports no significant complaints. Surgical site is healing well without signs of infection, erythema, or edema. Patient denies fever, chills, abdominal pain, nausea, vomiting, or abnormal vaginal bleeding or discharge. Review of systems is otherwise negative. Patient understands postoperative care instructions including wound care and signs and symptoms of potential complications such as infection or bleeding. Patient confirms understanding of the permanence of tubal ligation as a method of female sterilization and contraception. Plan is for routine follow-up as needed. Current procedural terminology (CPT) code: [Insert appropriate CPT code, e.g., 58670, 58671, 58600, 58605, depending on the procedure]. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code: Z30.2 (Encounter for sterilization). Keywords: Tubal ligation, sterilization, contraception, laparoscopy, mini-laparotomy, postoperative, follow-up, wound healing, complications, CPT code, ICD-10-CM, female surgical sterilization, permanent birth control, family planning.