New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 52 - HOSPITAL SERVICES MANUAL
Subchapter 2 - POLICIES AND PROCEDURES RELATED TO SPECIFIC SERVICES
Section 10:52-2.14 - Hysterectomy

Universal Citation: NJ Admin Code 10:52-2.14

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The Division covers hysterectomy procedures performed on Medicaid/NJ FamilyCare fee-for-service beneficiaries based on Federal regulations (42 CFR 441.250 through 441.258) and related requirements outlined in this section and in the billing instructions. For hysterectomy requirements see (b) through (d) below. In addition, see N.J.A.C. 10:52-1.13for the requirements for a Second Surgical Opinion for performing a hysterectomy.

(b) "Hysterectomy" means an operation for the purpose of removing the uterus.

1. A hysterectomy shall not be performed solely for the purpose of rendering an individual permanently incapable of reproducing. A hysterectomy shall be covered as a surgical procedure if performed primarily for the purpose of removing a pathological organ.

(c) Surgical hysterectomy procedures claim processing and reporting require the completion of the "Hysterectomy Receipt of Information Form (FD-189)" or, under certain conditions (see (d)1iii below), a physician certification. A second opinion shall be obtained and shall be submitted with the claim.

(d) The specific requirements to be met or documented on the "Hysterectomy Receipt of Information," (FD-189) form or, under certain conditions, a physician certification, shall be as follows:

1. A hysterectomy on a female of any age may be performed when medically necessary for a pathological indication, provided the person who secured authorization to perform the hysterectomy has:
i. Informed the individual and her representative (if any), both orally and in writing, that the hysterectomy will render the individual permanently incapable of reproducing; and,

ii. Ensures that the FD-189 form is completed and the individual or her representative has signed and dated a written acknowledgement of receipt of that information utilizing the FD-189 form; or,

iii. The physician who performed the hysterectomy certifies, in writing, that the individual:
(1) Was sterile before the hysterectomy (include cause of sterility); or,

(2) Required a hysterectomy because of a life-threatening emergency in which the physician determined that prior acknowledgement was not possible (include a description of the nature of the emergency); or,

(3) Was operated on during a period of the person's retroactive Medicaid/NJ FamilyCare-Plan A eligibility and the individual was informed, before the operation, that the hysterectomy would make her permanently incapable of reproducing or one of the conditions described in (d)1iii(1) or (2) above was applicable. (Include a statement that the individual was informed or describe which condition was applicable). "Retroactive Medicaid eligibility" means the consideration of unpaid medical bills incurred during a three-month period prior to the month the person applied for assistance. (See N.J.A.C. 10:49-2.9, Administration.) Although a physician certification is acceptable for situations described in (d)1iii above, the Division recommends that the FD-189 form be used whenever possible. There is no 30-day waiting period required before a medically necessary hysterectomy may be performed. The standard procedure for a surgical informed consent form within the hospital will suffice.

(e) Any New Jersey hospital with electronic billing capabilities shall submit a "hard copy" of the UB-92 claim form for all hysterectomy claims with the FD-189 form attached to the claim form and must not submit the claim through the EMC claim processing system.

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