HYSTERECTOMY
Federal regulations governing payment of a hysterectomy under Medicaid (Title XIX) prohibit payment for a hysterectomy under the following circumstances:
• If the hysterectomy is performed solely for the purpose of terminating reproductive capability
OR
• If there was more than one purpose for performing the hysterectomy, but the procedure would not have been performed except for the purpose of rendering the individual permanently incapable of reproducing.
According to Louisiana Medicaid Program guidelines, if a hysterectomy is performed, reimbursement can be made if:
1. The person who secured authorization to perform the hysterectomy has informed the individual and her representative* (see sample consent), if any, orally and in writing, that the hysterectomy will make the individual permanently incapable of reproducing; and
2. The individual or her representative, if any, has signed a written acknowledgement of receipt of that information.
These regulations apply to all hysterectomy procedures, regardless of the woman’s age, fertility, or reason for the surgery.
Consent for Hysterectomy
Providers may use BHSF Form 96-A for the hysterectomy consent form. A sample follows this section and may be copied for use.
The hysterectomy consent form must be signed and dated by the recipient on or before the date of the hysterectomy. The consent must include signed acknowledgement from the recipient stating they have been informed orally and in writing, that the hysterectomy will make the individual permanently incapable of reproducing.
The physician who obtains the consent should share the consent form with all providers involved in that patient’s care, (such as attending physician, hospital, anesthesiologist, and assistant surgeon) as each of these claims must have the valid consent form attached. To avoid a “system denial”, the consent must be attached to any claim submission related to a hysterectomy.
When billing for services that require a hysterectomy consent form, the name on the Medicaid file for the date of service in which the form was signed should be the same as the name signed at the time consent was obtained. If the patient name changes before the claim is processed for payment, the provider must attach a letter from the physician’s office from which the consent was obtained. The letter should be signed by the physician and should state that the patient’s name has changed and should include the patient’s social security number and date of birth. This letter should be attached to all claims requiring consent upon submission for claims processing A witness signature is needed on the hysterectomy consent when the recipient meets one of the following criteria:
• Recipient is unable to sign her name and must indicate “x” on signature line;
• There is a diagnosis on the claim that indicates mental incapacity. If a witness does sign the consent form, the signature date must match the date of the recipient signature. The witness must both sign and date the form; if the dates do not match or the witness does not sign and date the form, all claims related to the hysterectomy will deny.
Exceptions
Obtaining a hysterectomy consent is unnecessary in the following circumstances:
• The individual was already sterile before the hysterectomy, and the physician who performed the hysterectomy certifies in his own writing that the individual was already sterile at the time of the hysterectomy and states the cause of sterility.
• The individual required a hysterectomy because of a life-threatening emergency situation in which the physician determined that prior acknowledgment was not possible, and the physician certifies in his own writing that the hysterectomy was performed under these conditions and includes in his narrative a description of the nature of the emergency.
• The individual was retroactively certified for Medicaid benefits, and the physician who performed the hysterectomy certifies in his own writing that the individual was informed before the operation that the hysterectomy would make her permanently incapable of reproducing. In addition, if the individual was certified retroactively for benefits, and the hysterectomy was performed under one of the two other conditions listed above, the physician must certify in writing that the hysterectomy was performed under one of those conditions and that the patient was informed, in advance, of the reproductive consequences of having a hysterectomy.
In any of the above events, the written certification from the physician must be attached to the hard copy of the claim in order for the claim to be considered for payment.
