Hysterectomy is a benefit of the Colorado Medical Assistance Program when performed solely for medical reasons. Hysterectomy is not a benefit of the Colorado Medical Assistance Program if the procedure is performed solely for the purpose of sterilization, or if there was more than one purpose for the procedure and it would not have been performed but for the purpose of sterilization.
The following conditions must be met for payment of hysterectomy claims under the Colorado Medical Assistance Program. These claims must be filed on paper.
† Prior to the surgery, the person who secures the consent to perform the hysterectomy must inform the member and/or member’s representative verbally and in writing that the hysterectomy will render the member permanently incapable of bearing children.
† The member and/or member’s representative must sign a written acknowledgment that the member has been informed that the hysterectomy will render the member permanently incapable of reproducing. The written acknowledgment may be any form created by the provider that states specifically that, “I acknowledge that prior to surgery, I was advised that a hysterectomy is a procedure that will render me permanently incapable of having children.” The acknowledgment must be signed and dated by the member.
A written acknowledgment from the member is not required if:
† The member is already sterile at the time of the hysterectomy, or
† The hysterectomy is performed because of a life-threatening emergency in which the practitioner determines that prior acknowledgment is not possible.
If the member’s acknowledgment is not required because of the one of the above noted exceptions, the practitioner who performs the hysterectomy must certify in writing, as applicable, one of the following:
† A signed and dated statement certifying that the member was already sterile at the time of hysterectomy and stating the cause of sterility;
† A signed and dated statement certifying that the member required hysterectomy under a life-threatening, emergency situation in which the practitioner determined that prior acknowledgment by the member was not possible. The statement must describe the nature of the emergency.
A copy of the member’s written acknowledgment or the practitioner’s certification as described above must be attached to all claims submitted for hysterectomy services. A suggested form on which to report the required information is the Acknowledgment/Certification Statement for a Hysterectomy form located on the Department’s Web site. Providers may copy this form, as needed, for attachment
to claim(s). Providers may substitute any form that includes the required information. The submitted form or case summary documentation must be signed and dated by the practitioner performing the hysterectomy.
The surgeon is responsible for providing copies of the appropriate acknowledgment or certification to the hospital, anesthesiologist, and assistant surgeon for billing purposes. Claims will be denied if a copy of the written acknowledgment or practitioner’s statement is not attached.
Abortions
Induced Abortions
Therapeutic legally induced abortions are a benefit of the Colorado Medical Assistance Program when performed to save the life of the mother. The Colorado Medical Assistance Program also reimburses legally induced abortions for pregnancies that are the result of sexual assault (rape) or incest.
A copy of the appropriate certification statement must be attached to all claims for legally induced abortions performed for the above reasons. Because of the attachment requirement, claims for legally induced abortions must be submitted on paper and must not be electronically transmitted. Claims for spontaneous abortions (miscarriages), ectopic, or molar pregnancies are not affected by these
regulations.\
The following procedure codes are appropriate for identifying induced abortions:
59840 59841 59851 59852
59850 59855 59856 59857
Diagnosis code ranges:
635.00-635.92
637.00-637.92
Surgical diagnosis codes
69.01 69.51 69.93 74.91 75.0
Medicaid Coverage ABORTIONS
Medicaid only covers an abortion performed by a physician and related hospital charges (e.g., room, supplies) when it has been determined medically necessary to save the life of the mother or the pregnancy is the result of rape or incest. Medicaid funding is not available for any elective therapeutic abortion or service related to the performance of such abortion unless one of these criteria has been met. Physicians must certify on a completed Certification for Induced Abortion form (MSA-4240) that, for medical reasons, an abortion was necessary to save the life of the mother or the beneficiary’s medical history indicates that the terminated pregnancy was the result of rape or incest.
The physician who completes the MSA-4240 must also ensure completion of the Beneficiary Verification of Coverage form (MSA-1550) and is responsible for providing copies of the forms for billing purposes to any other provider (e.g., anesthesiologist, hospital, laboratory) that would submit claims for services related to the abortion.
Copies of the MSA-4240 and the MSA-1550 are not required for claims for ectopic pregnancies or spontaneous, incomplete, or threatened abortions.
Providers may attach copies of the MSA-4240 and the MSA-1550 to the claim or submit them via fax.
Federal regulations require that these forms be submitted to Medicaid before reimbursement can be made for any abortion procedure.
The medical record must include a complete beneficiary history, including the medical condition that made the abortion necessary to save the life of the mother. When the pregnancy is the result of rape or incest, the medical record must include the circumstances of the case and that the pregnancy was the result of rape or incest.
(Refer to the Forms Appendix for copies of MSA-4240 and MSA-1550. The forms are also available on the MDHHS website. Refer to the Directory Appendix for website and contact information.)
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