Circumcisions

Circumcisions A. Medicaid does not cover circumcisions unless medical necessity is documented in the medical record according to the criteria listed below. 1. A diagnosis which justifies the medical necessity for circumcision including, but not limited to, recurrent balanoposthitis or recurrent urinary tract infections; the diagnosis of phimosis alone is not sufficient documentation of medical necessity, 2. Failure of the patient to respond to conservative treatment; documentation of conservative treatment must include, but not limited to, teaching about appropriate hygiene and listing of appropriate drug therapy used to treat the condition, and 3. The recurrent nature of the medical condition. C. The medical documentation must be included either in the surgeon’s report or a beneficiary’s attending physician records to justify medical necessity. A pathology report alone is not sufficient as documentation of medical necessity. D. Documentation must be legible and available for review if requested. E. Medically necessary circumcisions may be performed in the inpatient hospital setting subject to precertification of all inpatient days, the outpatient hospital setting, the ambulatory surgical center, or a physician’s office. F. Reimbursement for hospital inpatient procedures will be included in the per diem rate of the facility and may be included in the cost report. 1. Facility charges for procedures performed in the outpatient department of the hospital will be reimbursed according to established Medicaid rates for outpatient hospital services. 2. Facility charges for procedures performed in an ambulatory surgical center are paid according to the Medicaid Ambulatory Surgical Center procedure schedule. 3. Physician fees are reimbursed based on the Medicaid Physician Fee Schedule. G. Appropriate anesthesia, which is considered the standard of care, is covered in accordance with the Division of Medicaid’s rules for anesthesia services. Refer to Part 203, Chapter 3.