Informed consent for sterilization must be documented by the
completion of the MassHealth 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 Acute Inpatient
Hospital 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 providers
must bill with the appropriate sterilization diagnosis and services 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
physician and the hospital), each provider must submit a copy of the completed
sterilization form with the claim.
(2) A provider 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; or
(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 415.411(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 415. 411(D)(2) (for example, the physician and hospital), each
provider must submit a copy of the signed attachment along with the
claim.
