SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)
Effective Date of Rule: January 1, 2011.
Purpose: The department is revising this section to include: (1) Coverage criteria for hysteroscopic sterilizations; and (2) equirements [requirements] for who can perform and be paid for this procedure.
Citation of Existing Rules Affected by this Order: Amending WAC 388-531-1550.
Statutory Authority for Adoption: RCW 74.08.090.
Adopted under notice filed as WSR 10-20-166 on October 6, 2010.
A final cost-benefit analysis is available by contacting Ellen Silverman, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1570, fax (360) 586-9727, e-mail firstname.lastname@example.org.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: November 30, 2010.
Katherine I. Vasquez
for Susan N. Dreyfus
MAA)) The department covers sterilization when all
of the following apply:
(a) The client is at least eighteen years of age at the time consent is signed;
(b) The client is a mentally competent individual;
(c) The client has voluntarily given informed consent in accordance with all the requirements defined in this subsection; and
(d) At least thirty days, but not more than one hundred eighty days, have passed between the date the client gave informed consent and the date of the sterilization.
MAA)) The department does not require the
thirty-day waiting period, but does require at least a
seventy-two hour waiting period, for sterilization in the
(a) At the time of premature delivery, the client gave consent at least thirty days before the expected date of delivery. The expected date of delivery must be documented on the consent form;
(b) For emergency abdominal surgery, the nature of the emergency must be described on the consent form.
MAA)) The department waives the thirty-day consent
waiting period for sterilization when the client requests that
sterilization be performed at the time of delivery, and
completes a sterilization consent form. One of the following
circumstances must apply:
(a) The client became eligible for medical assistance during the last month of pregnancy;
(b) The client did not obtain medical care until the last month of pregnancy; or
(c) The client was a substance abuser during pregnancy, but is not using alcohol or illegal drugs at the time of delivery.
MAA)) The department does not accept informed
consent obtained when the client is in any of the following
(a) In labor or childbirth;
(b) Seeking to obtain or obtaining an abortion; or
(c) Under the influence of alcohol or other substances that affect the client's state of awareness.
MAA)) The department has certain consent
requirements that the provider must meet before (( MAA)) the
department reimburses sterilization of a mentally incompetent
or institutionalized client. (( MAA)) The department requires
both of the following:
(a) A court order; and
(b) A sterilization consent form signed by the legal
guardian, sent to ((
MAA)) the department at least thirty days
prior to the procedure.
MAA)) The department reimburses epidural anesthesia
in excess of the six-hour limit for sterilization procedures
that are performed in conjunction with or immediately
following a delivery. (( MAA)) The provider cannot bill
separately for BAUs for the sterilization procedure. The
department determines total billable units by:
(a) Adding the time for the sterilization procedure to the time for the delivery; and
(b) Determining the total billable units by adding together the delivery BAUs, the delivery time, and the sterilization time.
(c) The provider cannot bill separately for the BAUs
for the sterilization procedure.))
(8) The physician identified in the "consent to
sterilization" section of the DSHS-approved sterilization
consent form must be the same physician who completes the
"physician's statement" section and performs the sterilization
procedure. If a different physician performs the
sterilization procedure, the client must sign and date a new
consent form at the time of the procedure that indicates the
name of the physician performing the operation under the
"consent for sterilization" section. This modified consent
must be attached to the original consent form when the
provider bills ((
MAA)) the department.
MAA)) The department reimburses all attending
providers for the sterilization procedure only when the
provider submits an appropriate, completed DSHS-approved
consent form with the claim for reimbursement. (( MAA)) The
department reimburses after the procedure is completed.
(10) The department pays for hysteroscopic sterilizations when the following criteria are met:
(a) A department-approved device is used;
(b) The procedure is predominately performed in a clinical setting such as a physician's office, without general anesthesia and without the use of a surgical suite; and is covered according to the corresponding department fee schedule;
(c) The client provides informed consent for the procedure in accordance with this section; and
(d) The hysteroscopic sterilization is performed by a department-approved provider who:
(i) Has a core provider agreement with the department;
(ii) Is nationally board certified in obstetrics and gynecology (OB-GYN);
(iii) Is privileged at a licensed hospital to do hysteroscopies;
(iv) Has successfully completed the manufacturer's training for the device;
(v) Has successfully performed a minimum of twenty hysteroscopies; and
(vi) Has established screening and follow-up protocols for clients being considered for hysteroscopic sterilization.
(12) To become a department-approved provider for hysteroscopic sterilizations, interested providers must send the department the following:
(a) Documentation of successful completion of the manufacturer's training;
(b) Documentation demonstrating privilege at a licensed hospital to perform hysteroscopies;
(c) Documentation attesting to having successfully performed twenty or more hysteroscopies; and
(d) Office protocols for screening and follow-up.
(10))) (13) Hysterectomies performed for medical
reasons may require expedited prior authorization as explained
in WAC 388-531-0200(2).
(11) MAA)) (14) The department reimburses hysterectomy
without prior authorization in either of the following
(a) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or
(b) The client is forty-six years of age or older.
(12) MAA)) (15) The department reimburses all attending
providers for the hysterectomy procedure only when the
provider submits an appropriate, completed DSHS-approved
consent form with the claim for reimbursement. If a prior
authorization number is necessary for the procedure, it must
be on the claim. (( MAA)) The department reimburses after the
procedure is completed.
[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1550, filed 12/6/00, effective 1/6/01.]
Reviser's note: The typographical errors in the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.