Hysterectomy reimbursement
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Defines Anthem New York Medicaid reimbursement requirements for nonelective and medically necessary hysterectomy procedures, including required consent/acknowledgement form and circumstances that are nonreimbursable; applies to covered members and providers billing Medicaid in New York.
07/17/2024 review approved and effective: no changes.
Hysterectomy Coverage Criteria
Hysterectomy coverage criteria
Anthem allows reimbursement when hysterectomy is nonelective and medically necessary and all consent requirements are met. Reimbursement is not allowed in specified circumstances.
ALL of the following
- Hysterectomy is medically necessary to treat an illness or injury.
- The member has given informed consent.
- The member or authorized representative is fully aware that the hysterectomy will render the member permanently incapable of reproducing and has verbally and in writing expressed this understanding.
- The member or authorized representative has signed and dated an applicable state-approved Consent/Acknowledgement of Hysterectomy form (required regardless of diagnosis or age).
Exceptions for prior consent
- A Consent/Acknowledgement of Hysterectomy form with the physician's certification is required.
- The member's prior informed Consent/Acknowledgement of Hysterectomy is not required.
ALL of the following
- A valid Consent/Acknowledgement of Hysterectomy form must be properly executed and include signatures from: the member (except as noted), the person obtaining consent, and the physician performing the hysterectomy.
- If performed in conjunction with delivery, multiple surgery guidelines apply (see Modifiers 50 and 51).
Not reimbursed (any of the following)
- The hysterectomy is performed for the sole purpose of rendering the member permanently incapable of reproduction.
- There is more than one reason for the hysterectomy, but the primary reason is to render the member permanently incapable of reproduction.
- The hysterectomy is performed for the purpose of cancer prophylaxis.
ALL of the following
- Claims submitted without a valid informed Consent/Acknowledgement of Hysterectomy form may be rejected, denied, recovered, or adjusted.
ALL of the following
- Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and receipt of a valid Consent/Acknowledgement of Hysterectomy form.
ALL of the following
- Applies to nonelective and medically necessary hysterectomy procedures for covered members unless provider, state, federal, or CMS contracts/requirements indicate otherwise.
ALL of the following
- A valid Consent/Acknowledgement of Hysterectomy form must include signatures from: member (except as noted), person obtaining consent, and the physician performing the hysterectomy.
ALL of the following
- If member was already sterile before hysterectomy or if hysterectomy was life‑threatening emergency where prior consent was not possible, physician certification on the Consent/Acknowledgement form is required and prior informed consent is not required.
ALL of the following
- When performed with delivery, follow multiple surgery guidelines (Modifiers 50 and 51: Multiple and Bilateral Surgery).
ALL of the following
- Claims for professional and/or facility services submitted without a valid informed Consent/Acknowledgement of Hysterectomy form may be rejected or denied.
ALL of the following
- Anthem considers reimbursement only when the above medical necessity and consent criteria are met.
ALL of the following
- This policy aligns with applicable state and federal requirements and references state‑approved Consent/Acknowledgement of Hysterectomy forms.
ALL of the following
- Ensure the Consent/Acknowledgement form is included with claims as required to support reimbursement eligibility.
ALL of the following
- Not reimbursed if performed for sole purpose of permanent infertility, if primary reason is to render member infertile, or for cancer prophylaxis.
ALL of the following
- Providers should follow authorization and medical necessity guidelines appropriate to the procedure and member's state of residence; improper coding may result in claim rejection, denial, recovery, or adjustment.
ALL of the following
- Required signatures on the Consent/Acknowledgement form: member (except as noted), person obtaining consent, and the physician performing the hysterectomy (three signatures).
Coding and Consent Requirements
| Bill with CPT, HCPCS, and/or revenue codes supported by medical record |
Provider Billing, Authorization, and Documentation Requirements
Consent/Acknowledgement Form Required
Anthem requires a valid, properly executed Consent/Acknowledgement of Hysterectomy form on file for reimbursement of nonelective, medically necessary hysterectomy procedures. The form must include signatures of the member (unless exception applies), the person obtaining consent, and the physician performing the hysterectomy. If the member was already sterile before the hysterectomy or the procedure was performed emergently when prior consent was not possible, include the Consent/Acknowledgement form with the physician’s certification documenting the circumstances.
- A valid state-approved Consent/Acknowledgement of Hysterectomy form is required regardless of member age or diagnosis.
- If consent could not be obtained due to a life‑threatening emergency, include the form plus the physician’s certification explaining why prior consent was not possible.
- Claims submitted without a valid Consent/Acknowledgement form may be rejected, denied, or recouped.
Multiple‑Surgery and Billing Guidance
When a hysterectomy is performed in conjunction with a delivery, follow Anthem’s multiple-surgery billing guidance. Providers must bill in accordance with applicable multiple and bilateral surgery modifier rules and the Modifiers 50 and 51: Multiple and Bilateral Surgery policy. Ensure documentation supports medical necessity for each procedure and include the required Consent/Acknowledgement form to avoid claim denials.
- Apply appropriate modifiers (e.g., Modifier 50, Modifier 51) per Anthem policy and coding guidelines.
- Document distinct medical necessity for the hysterectomy and for the delivery when both are performed.
- Include the Consent/Acknowledgement form with the claim when hysterectomy is performed with delivery to prevent denial or recoupment.
Referenced Definitions
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