CurrentBlue Cross Blue Shield - NevadaPolicy G-06057

Abortion (Termination of Pregnancy) reimbursement

This document governs Anthem Medicare Advantage reimbursement for abortions (induced, incomplete/missed/septic, and related procedures) and outlines consent, coding modifier, medical necessity, and billing expectations for providers across specified states.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAbortion (Termination of Pregnancy) reimbursement

Policy CodePolicy G-06057

Change TypeAdministrative review — no material changes

Effective Date

Next Review Date

Key ActionObtain written voluntary informed consent for induced abortions and append modifier G7 to the procedure code when requesting reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy history notes review approved with no changes as of 11/04/2024.

G7modifier to append for induced abortion reimbursement

Not requiredinformed consent for incomplete/missed/septic

Multipleapplies to states

Fee/Contractreimbursement basis

Coverage Criteria for Abortion and Related Treatments

Coverage criteria for abortion and related treatments

Covered when the following conditions are met:

Induced abortions are reimbursed when written voluntary informed consent has been obtained from the woman upon whom the abortion is to be performed.

ALL of the following

ONE of the following must be certified by the performing provider:
- The woman suffers from a physical disorder, injury, or illness (including a life‑endangering physical condition caused by or arising from the pregnancy) that, as certified by a physician, would place the woman in danger of death unless an abortion is performed.
- The pregnancy is the result of an act of rape or incest.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAbortion (Termination of Pregnancy) reimbursement

Policy CodePolicy G-06057

Change TypeAdministrative review — no material changes

Effective Date

Next Review Date

Key ActionObtain written voluntary informed consent for induced abortions and append modifier G7 to the procedure code when requesting reimbursement.

SourceLink

On This Page

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Coding and Documentation Requirements

Required modifier for induced abortionModifierCovered

G7	Modifier required to be appended to appropriate procedure code when requesting reimbursement for induced abortion procedures

Documentation support requirement

RequirementServices billed with CPT, HCPCS, and/or revenue codes must be fully supported in the medical record and/or office notes.

Billing guidanceUse industry‑standard, compliant codes on all claim submissions and proper billing/submission guidelines.

ConsequencesIf coding/billing guidelines or reimbursement policies are not followed, claims may be recouped, rejected/denied, or adjusted.

ApplicabilityPolicy applies to both participating and non‑participating professional providers and facilities unless otherwise noted.

Consent, Modifier, and Authorization Expectations

Note

Obtain informed consent and append modifier G7 for induced abortions

Obtain written voluntary informed consent from the woman for induced abortion procedures; append modifier G7 to the appropriate procedure code when requesting reimbursement. Note that informed consent is not required for treatment of incomplete, missed, or septic abortions, and consent forms are not required to be submitted with claims.

Written voluntary informed consent required for induced abortions; provider must certify qualifying condition (life‑endangering physical condition, rape, or incest).
Append modifier G7 to the appropriate procedure code when requesting reimbursement for induced abortion procedures.
Informed consent not required for treatment of incomplete, missed, or septic abortions; consent forms are not required to be submitted with claims.

Key Definitions

Induced/Elective abortion

DefinitionOne resulting from measures taken to intentionally end a pregnancy, using medications (medical abortion) or instrumentation (surgery).

Reimbursement noteInduced/elective abortions are reimbursed only as allowed by this policy and subject to provider/state/federal/CMS contracts and requirements.

Consent expectationWritten voluntary informed consent is required for induced abortions (see provider actions).

Incomplete abortion

DefinitionPart of the product of conception has been retained in the uterus.

Coverage stanceTreatment for incomplete abortions is covered as medically necessary and is not considered induced/elective; informed consent is not required for these treatments.

Clinical implicationProcedures should be billed with supporting documentation in the medical record/office notes.

Missed abortion

DefinitionA dead, nonviable fetus and other products of conception are retained in the uterus for two or more months.

Coverage stanceTreatment for missed abortions is covered as medically necessary and is not considered induced/elective; informed consent is not required for these treatments.

Clinical implicationDocument findings supporting diagnosis and treatment in the medical record/office notes.

Septic abortion

DefinitionInfection of the product of conception and the endometrial lining of the uterus, usually resulting from attempted interference during early pregnancy.

Coverage stanceSeptic abortion is treated as a medical condition requiring necessary treatment; informed consent for induced abortion is not required for septic abortion treatment.

Clinical implicationDocument signs of infection and treatments in the medical record/office notes to support billing and medical necessity.

Spontaneous/Miscarriage

DefinitionOccurs when a natural cause ends a pregnancy up to 20 weeks prior.

TerminologyAlso referred to as spontaneous abortion or miscarriage; distinguished from induced/elective abortion in coverage considerations.

DocumentationClinical documentation of timing (≤20 weeks) and natural cause should be in the medical record to support treatment and billing.