TMPPM 2010 > Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook > Gynecological Health Services > Hysterectomy Services > Hysterectomy Acknowledgment Form


7.5.1 Hysterectomy Acknowledgment Form

Hysterectomy services are considered for reimbursement when the claim is filed with a signed Hysterectomy Acknowledgment Form or documentation supporting that the Hysterectomy Acknowledgment Form could not be obtained or was not necessary.

All Texas Medicaid clients receiving hysterectomy services must sign a Hysterectomy Acknowledgment Form. The acknowledgment must be submitted to TMHP with the claim or to the client's health plan. All Texas Medicaid clients (including those in a STAR or STAR+PLUS Program health plan) receiving hysterectomy services must sign a Hysterectomy Acknowledgment Form. The acknowledgment must be submitted to TMHP with the claim or to the client's health plan.

The Hysterectomy Acknowledgement Form contains the acknowledgment statement of sterility by patient which informs clients that a hysterectomy will leave them permanently incapable of bearing children. According to federal and state regulations, reimbursement for a hysterectomy is available if the claim is filed with an acknowledgment statement, signed and dated by the client that indicates the client was informed both orally and in writing before the surgery that the hysterectomy would leave her permanently incapable of bearing children.

Each individual provider involved in the hysterectomy procedure is requested to submit a copy of a valid Hysterectomy Acknowledgment Form rather than relying on another provider. The client's eligibility file is updated upon receipt of the signed Hysterectomy Acknowledgment Form. Subsequent claims for services related to the hysterectomy are referenced to the valid acknowledgment form.

The provider is responsible for maintaining the original, signed copy of the Hysterectomy Acknowledgement Form in the client's medical record when a claim is submitted for consideration of payment. These records are subject to retrospective review.

When a hysterectomy, whether abdominal or vaginal, is performed without a client's acknowledgement form:

The hysterectomy procedure code is denied.

The other surgical procedures are evaluated for their clinical relevance.

Multiple procedures are processed according to the multiple surgery guidelines.

A Hysterectomy Acknowledgment Form is not required if the performing physician certifies that at least one of the following circumstances existed before the surgery:

The patient was already sterile before the hysterectomy, and the cause of the sterility is stated (e.g., congenital disorder, sterilized previously, or postmenopausal). Providers must use a post menopause or sterilization diagnosis code on the claim form. If the provider submits a claim and does not attach the acknowledgment, the provider must maintain the signed statement in the client's records, and the physician's signature will not be required on the claim form. These records are subject to retrospective review.

The patient requires a hysterectomy on an emergency basis because of a life-threatening situation. The physician must state the nature of the emergency and certify that it was determined that prior acknowledgment was not possible. Because the acknowledgment may be signed the day of or an hour before surgery, an emergency situation requires that the patient be unconscious or under sedation and unable to sign the acknowledgment.

Although the hysterectomy acknowledgement statement is not required if the criteria previously listed are met, the performing physician must certify that one or more of the circumstances existed prior to the surgery. This certification must be attached to the claim and signed by the performing provider.

For more information, refer to Title 42 of the Code of Federal Regulations (CFR) 441.255 and 25 TAC Part 1, Chapter 29, Subchapter F, section 25.501.

Refer to: Form GN.9, "Hysterectomy Acknowledgement Form" in this handbook.

Faxing Forms

All Medicaid providers may fax Hysterectomy Acknowledgment Forms to 1-512-514-4218. The form must include the client's Texas Medicaid number. All consent forms should be faxed with a cover sheet that identifies the provider and includes the telephone number and address. If the fax is incomplete or the consent form is invalid, the form is returned by mail or fax for correction. Completed consent forms that are faxed for adjustments or appeals are validated in the TMHP system. However, claims associated with the consent forms must be appealed through the mail to Appeals/Adjustments at the following address:

Texas Medicaid & Healthcare Partnership
Attn: Appeals/Adjustments
PO Box 200645
Austin, TX 78720-0645

Texas Medicaid & Healthcare Partnership
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