Current through Register Vol. 54, No. 44, November 2, 2024
(a) Except as specified in subsection (c), if
an individual is not sterile prior to the hysterectomy, payment will be made
for a hysterectomy only if all of the following requirements are met:
(1) The hysterectomy was medically necessary
and performed for a valid medical reason other than sterilization.
(2) The individual and her representative, if
any, were advised orally and in writing, before the operation, that the
hysterectomy would render the individual permanently incapable of
reproducing.
(3) The individual or
her representative, if any, has signed a written acknowledgement of receipt of
that information. The acknowledgement statement shall be signed and dated
before or after the operation. If the statement is signed after surgery, it
must clearly reflect that the individual was informed before the operation. See
the Provider Handbook for a facsimile of the Patient Acknowledgement Form for
Hysterectomy, MA 30, and for instructions on its
completion.
(b) Except as
specified in subsection (c), if the individual was already sterile, payment is
made for hysterectomy only if both of the following conditions are met:
(1) The physician who performed the
hysterectomy certified in writing that the woman was sterile prior to the
procedure and stated the cause of the sterility. Such reasons may include, but
are not limited to, congenital disorders, a previous sterilization or
postmenopausal sterility. A statement certifying the cause of sterility must be
noted on the invoice.
(2) The
hysterectomy was medically necessary.
(c) Payment is also made for a hysterectomy
performed, whether or not the patient was already sterile, if:
(1) The individual required a hysterectomy
because of a life threatening emergency situation in which the physician
determined that prior acknowledgement was not possible. The physician must
include a description of the nature of the emergency, documenting that prior
acknowledgement was not possible. A description of the nature of the emergency
must be noted on the invoice.
(2)
The hysterectomy was medically necessary and performed for a valid medical
reason other than sterilization.
The provisions of this §1141.56 issued under sections
403(a) and (b), 443.2(1) and (2), 443.3(1), 443.3(2)(i)-(v), 443.4 and 509 of
the Public Welfare Code (62 P. S. §§
403(a) and (b),
443.2(1) and (2), 443.3(1),
443.3(2)(i)-(v), 443.4 and 509).
This section cited in 55 Pa. Code §
1141.51 (relating to general
payment policy); 55 Pa. Code §
1141.52 (relating to payment
conditions for various services); and 55 Pa. Code §
1141.54 (relating to payment
conditions for inpatient services).
