Abortion — Treatment of Complications and Coverage Criteria
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This administrative policy describes Cigna coverage for abortion services and medically necessary treatment of complications following an abortion under standard Cigna benefit plans and explains relevant definitions and coding. It applies to providers submitting claims to Cigna and is governed by the terms of the applicable benefit plan and state regulations.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary treatment of complications
Covered when medically necessary under the terms of the applicable benefit plan
Standard Cigna benefit plans consider both elective and therapeutic abortion to be covered benefits.
Therapeutic abortion (coverage contingent on underlying condition)
Covered when diagnosis supports therapeutic abortion for maternal or fetal indications
Examples of indications include cancer; cardiovascular, hematologic or pulmonary disease; congenital heart disease; diabetes mellitus; ectopic pregnancy; exposure to a teratogenic substance; fetal genetic abnormalities; fetal death prior to viability; fetal structural defects; infectious disease with potential for significant complications (e.g., Zika); mental health and addiction disorders; metabolic disorders; pregnancy due to rape or incest; renal disease.
Spontaneous abortion (miscarriage) treatment
Covered management of spontaneous abortion and complications
Spontaneous abortion includes missed or incomplete abortion with retained products and infected/septic abortion, which may require medical or surgical treatment.
Ectopic pregnancy
Ectopic pregnancy is treated as a life‑threatening condition
Ectopic pregnancy may require urgent surgical intervention due to risk to the woman's life.
In the event of any conflict between this Administrative Policy and a customer's benefit plan document, the benefit plan document supersedes. Coverage determinations are made in consideration of the terms of the applicable benefit plan, applicable laws and regulations, relevant collateral materials (including Administrative Policies), and the specific facts of the situation. Coverage is subject to the terms, conditions, and limitations of the applicable benefit plan and any applicable state regulations.
An encounter is considered an elective abortion when ICD-10-CM code Z33.2 is billed alone or when Z33.2 is billed together with Z32.01. Use these diagnosis codes to identify elective termination of pregnancy in claims and documentation.
Ensure that all CPT and HCPCS codes submitted were valid and effective on the date of service. Deleted codes and codes not effective at the time the service is rendered may not be eligible for reimbursement. Policy code lists may not reflect the most recent AMA or CMS updates; providers should verify coding currency before billing.
Coding and Billing
| Z33.2 | Encounter for elective termination of pregnancy |
| Z32.01 | Encounter for pregnancy test, result positive |
| Z33.2 | Encounter for elective termination of pregnancy |
| Z32.01 | Encounter for pregnancy test, result positive |
| 59100 | Hysterotomy, abdominal (eg, for hydatidiform mole, abortion). |
| 59120 | Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach. |
| 59121 | Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy. |
| 59130 | Surgical treatment of ectopic pregnancy; abdominal pregnancy. |
| 59136 | Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus. |
| 59140 | Surgical treatment of ectopic pregnancy; cervical, with evacuation. |
| 59150 | Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy. |
| 59151 | Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy. |
| 59812 | Treatment of incomplete abortion, any trimester, completed surgically. |
| 59820 | Treatment of missed abortion, completed surgically; first trimester. |
| 59840 | Induced abortion, by dilation and curettage. |
| 59841 | Induced abortion, by dilation and evacuation. |
| 59850 | Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines. |
| 59851 | Induced abortion by intra-amniotic injections; with dilation and curettage and/or evacuation. |
| 59852 | Induced abortion by intra-amniotic injections; with hysterotomy (failed intra-amniotic injection). |
| 59855 | Induced abortion by vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines. |
| 59856 | Induced abortion by vaginal suppositories; with dilation and curettage and/or evacuation. |
| 59857 | Induced abortion by vaginal suppositories; with hysterotomy (failed medical evacuation). |
| 59866 | Multifetal pregnancy reduction(s) (MPR). |
| S0190 | Mifepristone, oral, 200 mg. |
| S0191 | Misoprostol, oral, 200 mcg. |
| S0199 | Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs. |
| S2260 | Induced abortion, 17 to 24 weeks. |
| S2265 | Induced abortion, 25 to 28 weeks. |
| S2266 | Induced abortion, 29 to 31 weeks. |
| S2267 | Induced abortion, 32 weeks or greater. |
| Z33.2 | Encounter for elective termination of pregnancy. |
| Z32.01 | Encounter for pregnancy test, result positive. |
Provider Actions and Billing Guidance
Confirm plan/state coverage rules
Coverage for abortion is governed by the terms, conditions and limitations of the applicable benefit plan and may also be subject to state regulations; standard Cigna benefit plans consider both elective and therapeutic abortion to be covered benefits.
Verify procedure code aligns with diagnosis
When billing therapeutic abortion or related procedure codes, ensure the procedure/CPT/HCPCS code is accompanied by diagnosis code(s) that indicate an underlying maternal or fetal condition consistent with the clinical indication.
- Procedure codes listed for therapeutic abortion must correspond to diagnosis codes reflecting maternal health or fetal disease.
Follow benefit document and legal requirements
Coverage determinations require review of the applicable benefit plan document, any applicable laws/regulations, relevant collateral materials (including Administrative Policies), and the specific facts of the situation; the customer’s benefit plan document supersedes the Administrative Policy in the event of a conflict.
Ensure code currency to avoid denial
Deleted codes and codes not effective on the date of service may not be eligible for reimbursement; verify code currency before submission.
Elective abortion coding guidance (Z33.2)
Elective abortion is indicated when ICD-10-CM code Z33.2 (Encounter for elective termination of pregnancy) is billed alone or billed with Z32.01.
- Z33.2 billed alone or with Z32.01 denotes elective termination.
Align coding and documentation with clinical indication
Use current, effective CPT and HCPCS codes and ensure diagnosis codes document the underlying maternal or fetal condition when billing therapeutic abortion procedure codes.
- Verify CPT/HCPCS code effective date and applicability.
- Document diagnosis codes that support therapeutic indication.
Base coverage decisions on plan, law, and facts
Coverage determinations are based on the terms of the applicable benefit plan document, applicable laws and regulations, relevant collateral materials (including Administrative Policies), and the specific facts of the situation; follow these sources when making or justifying coverage requests.
Confirm code effectiveness before billing
Verify that the CPT/HCPCS code used was effective and not deleted on the date the service was rendered; codes deleted or not effective at time of service may be denied.
Definitions
Background
Abortion is the induced or spontaneous termination of pregnancy and may be performed for elective reasons or for therapeutic indications related to maternal health or fetal disease. Abortion procedures can be medical (for example, medication regimens such as mifepristone plus misoprostol) or surgical (for example, dilation and curettage or evacuation). Spontaneous abortion (miscarriage) and its complications — including missed, incomplete, or infected/septic abortion — are managed using appropriate medical or surgical treatment codes. Ectopic pregnancy is a nonviable, potentially life‑threatening condition that may require immediate surgical intervention; surgical CPT codes for ectopic pregnancy and related procedures are provided in the policy.
Revision History
Policy A006 (Abortion) became effective for standard Cigna benefit plans; coverage affirms medically necessary treatment of complications following an abortion and lists coding and clinical guidance.
Next scheduled review date for Policy A006 (Abortion).
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