N.J. Admin. Code § 10:54-5.42 - Hysterectomy

(a) The Division will cover hysterectomy procedures performed on Medicaid beneficiaries based on Federal regulation ( 42 CFR 441.250 through 42 CFR 441.258 ) and related requirements outlined in the billing instructions. For billing instructions, see Fiscal Agent Billing Supplement, Appendix B.

(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) Certain hysterectomy procedures require the completion of the "Hysterectomy Receipt of Information Form (FD-189, Rev. 7/83) or, under certain conditions, (see (d)1iii, below) a physician certification.

(d) The specific requirements to be met and/or documented on the Hysterectomy Receipt of Information Form (FD-189, Rev. 7/83) or, under certain conditions, a physician certification are:

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. Ensured that the "Hysterectomy Receipt of Information" (FD-189, Rev. 7/83) is completed and the individual or her representative has signed and dated a written acknowledgement of receipt of that information utilizing the "Hysterectomy Receipt of Information Form" (FD-189, Rev. 7/83); or

iii. The physician who performed the hysterectomy certifies, in writing, that the individual:

(1) Was sterile before the hysterectomy (include cause of sterility);

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

(3) Was operated on during a period of the person's retroactive Medicaid/NJ FamilyCare program eligibility (see 10:49-2.7 ) 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 (1) or (2) above was applicable (include a statement that the individual was informed or describe which condition was applicable).

(e) Although a physician certification is acceptable for situations described in (d)1iii above, the Division recommends that the Hysterectomy Receipt of Information Form (FD-189) be used whenever possible.

(f) There is no 30 day waiting period required before a medically necessary hysterectomy may be performed. The standard procedure for surgical consent forms will prevail.

(g) Any New Jersey physician with electronic billing capabilities shall submit a "hard copy" of the CMS 1500 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 claims processing.

Notes

N.J. Admin. Code § 10:54-5.42

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (a), substituted "beneficiaries" for "recipients" following "performed on Medicaid".
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (d)1iii(1), deleted "or" from the end; in (d)1iii(3), inserted "/NJ FamilyCare program"; and in (g), substituted "CMS" for "HCFA".