Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

55 Pa. Code § 1141.56. Payment conditions for hysterectomies.

§ 1141.56. Payment conditions for hysterectomies.

 (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.

Authority

   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).

Source

   The provisions of this §  1141.56 adopted August 15, 1980, effective September 1, 1980, 10 Pa.B. 3386; amended December 2, 1983, effective August 4, 1982, 13 Pa.B. 3758; amended September 7, 1984, effective July 1, 1984, 14 Pa.B. 3252. Immediately preceding text appears at serial pages (86760) to (86761).

Cross References

   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).



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