ModifiedDHAPolicy 6010.60-M

Abortions

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Coverage criteria, exclusions, provider documentation, and coding requirements for abortions within the Obstetrics/Gynecology service domain.

Policy Summary

PayerDHA

PolicyAbortions

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateJan 2, 2013

Next Review DateN/A

Key ActionFor covered abortions, document the applicable indication and submit the required G7 modifier, condition code, and TRICARE Encounter Data special processing code.

SourceLink

POLICY UPDATE CHANGES

Revision 86 revised abortion coverage to prohibit cost-sharing except when the pregnancy resulted from rape or incest or when carrying the fetus to term would endanger the mother's life.

Revision 86 added coverage for services and supplies related to spontaneous, missed, threatened, and ectopic abortions and for medically and psychologically necessary services related to a covered abortion.

Revision 86 added claim-form, modifier, condition-code, CPT-code, and TRICARE Encounter Data requirements for covered abortions.

3Covered indications

G7Required modifier

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ModifiedDHAPolicy 6010.60-M

Abortions

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Sign up for DHA Policy 6010.60-M alerts

Get alerted when Policy 6010.60-M changes without checking for updates manually.

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Coverage criteria, exclusions, provider documentation, and coding requirements for abortions within the Obstetrics/Gynecology service domain.

Policy Summary

PayerDHA

PolicyAbortions

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateJan 2, 2013

Next Review DateN/A

Key ActionFor covered abortions, document the applicable indication and submit the required G7 modifier, condition code, and TRICARE Encounter Data special processing code.

SourceLink

POLICY UPDATE CHANGES

Revision 86 revised abortion coverage to prohibit cost-sharing except when the pregnancy resulted from rape or incest or when carrying the fetus to term would endanger the mother's life.

Revision 86 added claim-form, modifier, condition-code, CPT-code, and TRICARE Encounter Data requirements for covered abortions.

3Covered indications

G7Required modifier

Covered and Excluded Abortion Services

Covered induced abortion indications

Abortions are cost-shared when at least one of the following covered indications applies:

Covered abortion indication

Rape: The pregnancy is the result of an act of rape.
The patient's medical record must contain a physician's note supporting the provider's good-faith belief, based on all information available to the provider, that the patient was the victim of rape.
Incest: The pregnancy is the result of an act of incest.
The patient's medical record must contain a physician's note supporting the provider's good-faith belief, based on all information available to the provider, that the patient was the victim of incest.
Life endangerment: Carrying the fetus to term would endanger the mother's life.
A physician must certify that the abortion was performed because the mother's life would have been endangered by carrying the fetus to term.

Related services and supplies

The following services and supplies are cost-shared when related to an applicable covered condition or covered abortion.

Covered related services and supplies: Services and supplies related to spontaneous, missed, or threatened abortions; abortions related to ectopic pregnancies; and medically or psychologically necessary services and supplies related to a covered abortion are covered.

Covered related care includes ultrasound performed before the abortion, pathology services, pregnancy tests, office visits, applicable state or local legal requirements, and otherwise covered follow-up care such as psychotherapy.

Rape or incest drug coverage

Drug and associated-service coverage applies when the pregnancy resulted from rape or incest.

Covered abortion drugs and associated services: The pregnancy is the result of an act of rape or incest, and the treatment includes drugs such as Mifeprex (HCPCS S0190) or misoprostol (HCPCS S0191), with associated services and supplies (HCPCS S0199).

Services and supplies related to a noncovered abortion are excluded from coverage.

Abortion counseling, referral, preparation, and follow-up are excluded when provided for a noncovered abortion.

Abortions performed because of a fetal abnormality, such as anencephaly, or for psychological reasons, such as threatened suicide, are excluded.

Selective reduction of multifetal gestations, including CPT 59866, is excluded unless carrying the multifetal gestation to term would endanger the mother's life.

Covered and Excluded Billing Codes

CPT Procedure Code RangeCPT

59812-59857	CPT procedure code range
59866	CPT procedure code

HCPCS CodesHCPCSCovered

S0190	Mifeprex
S0191	Misoprostol
S0199	Associated services and supplies

G7 ModifierModifierCovered

G7	The pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening

Condition CodesRevenueCovered

AA	Abortion performed due to rape
AB	Abortion performed due to incest
AD	Abortion performed due to life endangering physical condition

Hospital Outpatient and Professional Billing CPT CodesCPTCovered

59840	CPT procedure code
59841	CPT procedure code
59850-59852	CPT procedure code range
59855-59857	CPT procedure code range
59866	CPT procedure code

TRICARE Encounter Data Special Processing CodesRevenueCovered

AE	Abortion performed due to rape
AF	Abortion performed due to incest
AG	Abortion performed due to life endangering physical condition

Excluded CPT ProcedureCPTNot Covered

59866

Selective reduction of multi-fetal gestations

Documentation and Claims Requirements

Documentation Required

Physician Note Required for Rape or Incest

For an abortion covered because the pregnancy resulted from rape or incest, maintain a physician's note in the patient's medical record supporting the provider's good-faith belief, based on all information available to the provider, that the patient was the victim of rape or incest.

Documentation Required

Physician Certification for Life Endangerment

For an abortion covered because carrying the fetus to term would endanger the mother's life, obtain and maintain a physician certification attesting that the abortion was performed for that life-endangerment reason.

Billing Rule

Policy Scope and Context

This policy addresses abortion, defined as the intentional termination of a pregnancy by artificial means for a purpose other than producing a live birth. Coverage distinguishes noncovered abortions from covered abortions related to rape, incest, or danger to the mother's life; it also provides coverage for spontaneous, missed, threatened, and ectopic abortions and for medically or psychologically necessary services related to a covered abortion.

Key Definition

Definitions

TermAbortion

DefinitionThe intentional termination of a pregnancy by artificial means done for a purpose other than that of producing a live birth.