Instructions for Filling Out a Hysterectomy Statement

For a downloadable version of this communication to save and reference when completing the form, please see the link to the right. 

Completing the Form - This guide will assist in correct completion of the Hysterectomy Statement and should help to decrease the number of denials related to errors in completing the form.  Providers remain responsible for all guidelines set forth in NC Medicaid 1E-1 Hysterectomy policy that may not be addressed in this guidance document.

The hysterectomy statement must be downloaded from the DHB website. The date at the bottom of the form should read 11.01.2013. The hysterectomy statement must be printed on the provider’s professional letterhead and may not be altered in any way. The use of white out is not acceptable.

Providers are encouraged to pay special attention to filling out the correct section of the statement:

  • If the recipient signed the statement on or before the day of surgery, complete section 1
  • If the recipient signed the statement after the day of surgery, complete section 2
  • If the recipient was sterile prior to surgery, complete section 3
  • If the hysterectomy was performed due to a life-threatening situation complete section 3 and include medical records with the hysterectomy statement

Health record documentation must be submitted for the following individuals and diagnoses:

  • Individuals under the age of 21;
  • Pelvic inflammatory disease;
  • Mild to moderate cervical dysplasia, when prior conservative procedures failed;
  • Carcinoma in situ of unspecified organs; and
  • Uterine hemorrhage from placenta previa.

The health record documentation must include history and physical, operative notes, pathology report, discharge summary and reports for treatments performed prior to the hysterectomy. The health records should support the medical necessity for the hysterectomy.

The NPI field should be populated with the provider’s individual NPI.  Also complete the beneficiary identification number (RID-Recipient Identification number). Make sure both are valid and legible.

Patient name must be complete and legible (full first and last name, no initials). The name must match the name on the eligibility file for the beneficiary ID (RID) unless a name change statement is included with the hysterectomy consent.

The recipient signature must be complete and legible (full first and last name, no initials) and must match the printed name. If the recipient signs the consent with an ‘X’ there must be 2 witness signatures included.

If the recipient is under 21 years of age, the recipient’s legal guardian and a second witness signature must be included.

If the recipient is mentally incompetent the consent form must be signed by the recipient’s legal guardian and a second witness.

Patient address must be complete (please do not abbreviate name of the city).

Witness name must be complete (full first and last name, no initials).

Witness signature must be complete (full first and last name, no initials).

Date recipient signed form must be complete.

Check to be sure date of surgery is correct.

When completing section 3, fill in recipient name and address. If recipient was sterile prior to hysterectomy, list the reason. If recipient is unable to respond due to a life-threatening situation, list reason and include medical records. In 3rd section, provider must print name, signature and date. Use of stamps is not acceptable.

Improperly worded, incomplete, altered or traced hysterectomy statements cannot be accepted.