Informed consent for sterilization must be documented by the
completion of the MassHealth agency's Consent for Sterilization form in
accordance with the following requirements. (Instructions for obtaining the
Consent for Sterilization forms are located in Subchapter 5 of the
Community Health Center Manual.)
(A)
Required Consent
Form.
(1) One of the following
Consent for Sterilization forms must be used:
(a) CS-18 for members 18 through 20 years of
age; or
(b) CS-21 for members 21
years of age or older.
(2) Under no circumstances will the
MassHealth agency accept any other consent for sterilization form.
(B)
Required
Signatures. The member, the interpreter (if one was required), and
the person who obtained the consent for sterilization must all sign and date
the Consent for Sterilization form (CS-18 or CS-21) at the time of consent.
After performing the sterilization procedure, the physician must sign and date
the form.
(C)
Required
Distribution of the Consent Form. The Consent for Sterilization
form (CS-18 or CS-21) must be completed and distributed as follows:
(1) the original must be given to the member
at the time of consent; and
(2) a
copy must be included in the member's permanent medical record at the site
where the sterilization is performed.
(D)
Provider Billing and Required
Submissions.
(1) All CHCs must
bill with the appropriate sterilization diagnosis and service codes, and must
attach a copy of the completed Consent for Sterilization Form (CS-18 or CS-21)
to each claim made to the MassHealth agency for sterilization services. This
provision applies to any medical procedure, treatment, or operation for the
purpose of rendering an individual permanently incapable of reproducing. When
more than one provider is billing the MassHealth agency (for example, the CHC
and a hospital), each provider must submit a copy of the completed
sterilization consent form with the claim.
(2) A CHC does not need to submit a Consent
for Sterilization form (CS-18 or CS-21) with a claim for a medical procedure,
treatment, or operation that is not for the purpose of rendering an individual
permanently incapable of reproducing. If the appropriate service code used to
bill for such a medical procedure, treatment, or operation may also be used to
bill for a sterilization, the claim will be denied unless at least one of the
following justifications is present and documented on an attachment signed by
the physician and attached to the claim.
(a)
The medical procedure, treatment, or operation was a unilateral procedure and
did not result in sterilization.
(b) The medical procedure, treatment, or
operation was unilateral or bilateral, but the patient was previously sterile
as indicated in the operative notes.
(c) The medical procedure, treatment, or
operation was medically necessary for treatment of an existing illness or
injury and was not performed for the purpose of sterilization.
(d) The medical procedure, treatment, or
operation was medically necessary for treatment of a life-threatening emergency
situation and was not performed for the purpose of sterilization, and it was
not possible to inform the member in advance that it would or could result in
sterilization. Include the nature and date of the life-threatening
emergency.
(3) In the
circumstances set forth in
130 CMR
405.430(D)(2)(a) and (c),
the medical records must also document that the member consented to the medical
procedure, treatment, or operation after being informed that it would or could
result in sterilization.
(4) When
more than one provider is billing the MassHealth agency under the circumstances
specified in
130 CMR
405.430(D)(2), (for example,
the CHC and a hospital), each provider must submit a copy of the signed
attachment along with the claim.
