36.4.16.5 Hysterectomy ServicesProviders can use any of the following procedure codes to submit claims for hysterectomy procedures:
Assistant surgeons may be reimbursed when assisting a surgeon performing a surgical laparoscopy with vaginal hysterectomy (procedure code 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, or 58554). Note: All Medicaid clients receiving hysterectomy services, including those in a STAR or STAR+PLUS Program health plan, must sign a Hysterectomy Acknowledgment Form. The acknowledgment must be submitted to the client's health plan. Texas Medicaid reimburses hysterectomies when they are medically necessary. Texas Medicaid does not reimburse hysterectomies performed for the sole purpose of sterilization. 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. 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. A Hysterectomy Acknowledgment Form is not required if the performing physician certifies and signs the claim form or attachment that states at least one of the following circumstances existed before the surgery:
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• 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. 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:
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• A hysterectomy acknowledgment statement is not required when one or more of the following circumstances exist:
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• Although the hysterectomy acknowledgement statement is not required if the above criteria 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 42 CFR 441.255 and 25 TAC Part 1, Chapter 29, Subchapter F, section 25.501. Refer to: "Hysterectomy Acknowledgment Form". Faxing Forms All Medicaid providers may fax Hysterectomy Acknowledgment Forms to 1-512-514-4218. The form must include the client's 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 |
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 postmenopause 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.
