Clinical Policy 1E-3, Sterilization Procedures - Sterilization Consent Form

Consent Form Expiration Date

NC Medicaid has been notified by the Centers for Medicare & Medicaid Services (CMS) that the 180-day signature requirement on the federal sterilization consent form cannot be waived. The requirement for beneficiary signature at least 30 days prior to a sterilization procedure is also still in effect. (The exception to this 30-day requirement is outlined in the sterilization policy).

NC Medicaid providers with beneficiaries who have had delayed surgery due to the COVID-19 public health emergency and for whom the 180-day expiration has passed will need to obtain a new informed consent at least 30 days prior to the date of the surgery.    

NC Medicaid recommends providers with beneficiaries who have signed consent forms close to 150 days old have those beneficiaries resign tubal sterilization consent forms to reset the 180-day signature requirement. This provider visit may be conducted in a drive-thru outdoor setting as well as in the office.

Clarifications Related to Aug. 15, 2020 Policy Update

• Effective with procedures on or after Aug. 15, 2020, the Type of Operation specified under the Physician’s Statement section of the sterilization consent form for total salpingectomy procedures should be PBS or Prophylactic Bilateral Salpingectomy.

  In addition, NC Medicaid will be monitoring that the Type of Operation specified under the Physician’s Statement section of the sterilization consent form matches the procedure billed on the claim. Acceptable procedure wording/abbreviation and Current Procedural Terminology (CPT) procedure code combinations are listed below. 

• Providers are also reminded that the FP modifier is required on all claims for sterilization procedures. 

Providers are encouraged to review Clinical Policy 1E-3, Sterilization Procedures and NC Medicaid Provider Bulletin Clinical Policy 1E-3, Sterilization Procedures Revised Effective Aug. 15, 2020 for updates and guidance on billing and completing the sterilization consent form.

In addition, the NCTracks team has put together detailed instructions for filling out the Federal Sterilization Consent form, complete with explanations for each field of the form, to better help providers submit accurate information and eliminate errors that may cause denials. Providers are encouraged to download this PDF guide here under Provider Policies, Manuals and Guidelines to learn from and reference when completing the form.

Contact

NCTracks Contact Center: 800-688-6696