In NY, there are 2 different forms for Medicaid patients commonly used in gyn.
One is a hysterectomy consent form (LDSS-3113)
https://www.health.ny.gov/health_care/medicaid/publications/docs/ldss/ldss-3113.pdf
We use this form for any procedure removing the uterus.
It is signed by the patient and the provider unless the patient is already incapable of bearing children, in which case only the provider needs to sign. There are no specific timeframe requirements I am aware of. We typically have this form completed during the appointment discussing a hysterectomy.
The other is a sterilization consent form (LDSS-3134)
https://www.health.ny.gov/health_care/medicaid/publications/docs/ldss/ldss-3134.pdf
We use this form only for procedures being done for sterilization purposes. We do not use them for patients having salpingectomies or salpingo-oophorectomies for medical reasons.
This form must be signed by the patient and physician at least 30 days but < 180 days prior to procedure, and then again by the physician following the procedure. When performed in NYC, it must also be witnessed and there are additional requirements about who can obtain the patient consent.
I am not aware of any specific list of CPT codes requiring those forms.
EMEDNY gives more complete instructions for both here, but does not list CPT codes. The bulk of my gyn experience is in gynonc and we use the hysterectomy consent form daily, but rarely the sterilization consent form. The NY Medicaid HMOs require these forms as well (Affinity, Fidelis, HealthFirst, UHC Community Plan), so we simply have any hysterectomy patient sign regardless of insurance. I recall nly once getting a denial for a BSO on a patient with an ovarian cyst asking for sterilization form. I simply wrote a letter explaining it was not a sterilization procedure and claim was reprocessed. I think most carriers require the
sterilization form based on DIAGNOSIS submitted rather than procedure. And the hysterectomy form is based on procedure.