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Medicaid Requirements for Surgical Procedures for Hysterectomies, Sterilizations and Abortions (1.2.18)

Medicaid Requirements for Surgical Procedures for Hysterectomies, Sterilizations and Abortions (1.2.18) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.18


UW HEALTH CLINICAL POLICY 1
Policy Title: Medicaid Requirements for Surgical Procedures for Hysterectomies,
Sterilizations, and Abortions
Policy Number: 1.2.18
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 23, 2017

I. PURPOSE

To provide guidelines for clinic staff and providers that are consistent with the Wisconsin Medical Assistance
(WMA) Provider Handbook with regards to the scheduling of selected surgical procedures for patients with
Medical Assistance.

II. POLICY ELEMENTS

This policy must be followed for all female patients with Medicaid having a hysterectomy or abortion, and all
female and male patients with Medicaid having a sterilization procedure.

Compliance with surgical procedure documentation requirements for patients with Wisconsin Medical
Assistance (WMA) must be followed to ensure proper reimbursement.

Completed forms are required to be filed in patient's electronic medical record prior to surgery.

III. PROCEDURE

A. HYSTERECTOMIES - Hysterectomies are reimbursable if and only if the following conditions are met:
i. An Acknowledgment of Receipt of Hysterectomy Information form must be completed prior to a
covered hysterectomy, except in the circumstances noted below.
ii. The form can be attached to the paper 1500 Health Insurance Claim Form. This form can also be
uploaded via the ForwardHealth Portal for electronically submitted claims or providers may submit
a paper claim and send the attachment electronically.
iii. Wisconsin Medicaid does not cover a hysterectomy for uncomplicated fibroids, fallen uterus, or
retroverted uterus.
iv. A hysterectomy may be covered without a valid acknowledgment form if one of the following
circumstances applies:
a. The member was already sterile. Sterility may include menopause. (The physician is
required to state the cause of sterility in the member's medical record.)
b. The hysterectomy was required as the result of a life-threatening emergency situation in
which the physician determined that a prior acknowledgment of receipt of hysterectomy
information was not possible. (The physician is required to describe the nature of the
emergency.)
c. The hysterectomy was performed during a period of retroactive member eligibility and one
of the following circumstances applied:
1. The member was informed before the surgery that the procedure would make
her permanently incapable of reproducing.
2. The member was already sterile.
3. The member was in a life-threatening emergency situation which required a
hysterectomy.
v. For all of the exceptions previously listed, the physician is required to identify, in writing, the
applicable circumstance and attach the signed and dated documentation to the paper claim. (A
copy of the preoperative history/physical exam and operative report is usually sufficient.)
vi. The Acknowledgment of Receipt of Hysterectomy Information form is not to be used for purposes
of consent of sterilization. Wisconsin Medicaid does not cover hysterectomies for the purposes of
sterilization.
B. STERILIZATIONS - A sterilization is any surgical procedure performed with the primary purpose of
rendering an individual permanently incapable of reproducing. The procedure may be performed in an
"open" or laparoscopic manner. This does not include procedures that, while they may result in sterility, have
a different purpose such as surgical removal of a cancerous uterus or cancerous testicles.
i. Providers should refer to the physician services maximum allowable fee schedule for allowable
sterilization procedure codes.



UW HEALTH CLINICAL POLICY 2
Policy Title: Medicaid Requirements for Surgical Procedures for Hysterectomies, Sterilizations, and Abortions
Policy Number: 1.2.18

ii. Medicaid reimbursement for sterilizations is dependent on providers fulfilling all federal and state
requirements and satisfactory completion of a Consent for Sterilization form. There are no
exceptions. Federal and state regulations require the following:
a. The member is not an institutionalized individual.
b. The member is at least 21 years old on the date the informed written consent is obtained.
c. The member gives voluntary informed written consent for sterilization.
d. The member is not a mentally incompetent individual. Wisconsin Medicaid defines a
"mentally incompetent" individual as a person who is declared mentally incompetent by a
federal, state, or local court of competent jurisdiction for any purposes, unless the
individual has been declared competent for purposes that include the ability to consent to
sterilization.
e. At least 30 days, excluding the consent and surgery dates, but not more than 180 days,
must pass between the date of written consent and the sterilization date, except in the
case of premature delivery or emergency abdominal surgery if:
1. In the case of premature delivery, the sterilization is performed at the time of
premature delivery and written informed consent was given at least 30 days
before the expected date of delivery and at least 72 hours before the premature
delivery. The 30 days excludes the consent and surgery dates.
2. The sterilization is performed during emergency abdominal surgery and at least
72 hours have passed since the member gave written informed consent for
sterilization.
iii. Consent for Sterilization Form
a. A member must give voluntary written consent on the federally required Consent for
Sterilization form. Sterilization coverage requires accurate and thorough completion of the
consent form. The physician is responsible for obtaining consent. Any corrections to the
form must be signed and dated by the physician and/or member, as appropriate.
b. Signatures and signature dates of the member, physician, and the person obtaining the
consent are mandatory. Providers' failure to comply with any of the sterilization
requirements results in denial of the sterilization claims.
c. The completed consent form can be uploaded via the ForwardHealth Portal for
electronically submitted claims or be attached to a paper 1500 Health Insurance Claim
Form to obtain reimbursement.
iv. Sterilization with Placement by Permanent Implant
a. The professional service for CPT procedure code 58565 (Hysteroscopy, surgical; with
bilateral fallopian tube cannulation to induce occlusion by placement of permanent
implants) and the implantable device are reimbursed under separate procedure codes.
b. The professional service only is reimbursed under procedure code 58565.
c. The implantable device is reimbursed under HCPCS procedure code A4264 (Permanent
implantable contraceptive intratubal occlusion device[s] and delivery).
d. Providers are required to bill their usual and customary fee for services provided to
Wisconsin Medicaid and BadgerCare Plus members.
e. Providers are required to complete and submit the Consent for Sterilization form when
billing these services.
C. Abortions: In accordance with s. 20.927, Wis. Stats., abortions are covered when one of the following
situations exists:
i. The abortion is directly and medically necessary to save the life of the woman, provided that prior
to the abortion the physician attests, based on his or her best clinical judgment, that the abortion
meets this condition by signing a certification.
ii. In a case of sexual assault or incest, provided that prior to the abortion the physician attests that
sexual assault or incest has occurred, to his or her belief, by signing a written certification; the
crime must also be reported to the law enforcement authorities.
iii. Due to a medical condition existing prior to the abortion, provided that prior to the abortion the
physician attests, based on his or her best clinical judgment, that the abortion meets the following
condition by signing a certification that the abortion is directly and medically necessary to prevent
grave, long-lasting physical health damage to the woman.
iv. When submitting a claim to ForwardHealth, physicians are required to attach or upload via the
ForwardHealth Portal a completed and signed certification statement attesting to one of the
previous circumstances. The optional Abortion Certification Statements form is available to use in
this situation.



UW HEALTH CLINICAL POLICY 3
Policy Title: Medicaid Requirements for Surgical Procedures for Hysterectomies, Sterilizations, and Abortions
Policy Number: 1.2.18


IV. FORMS

Wisconsin Medical Assistance (WMA) requires documentation for the surgical procedures listed in Section
IV. Forms are available at https://www.forwardhealth.wi.gov. Choose "Providers." Then choose "Forms" from
the "Quick Links" area.
- Acknowledgment of Receipt of Hysterectomy Information, # F-01160
- Consent for Sterilization, #F-01164
- Abortion Certification Statements, #F-1161

V. COORDINATION

Author: Ob-Gyn Associate Administrator & Director of Clinical Operations
Approval committees: Ob-Gyn Clinical Operations Committee, UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: October 16, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

Wisconsin Medical Assistance Provider Handbook, https://www.forwardhealth.wi.gov/WIPortal/

VIII. REVIEW DETAILS

Version: Revision
Last Full Review: October 2017
Next Revision Due: October 2020
Formerly Known as: UWHC policy #7.54