CurrentPremera BluecrossPolicy N/A

Abortion procedure coding and coverage identification

Defines how the Plan identifies and codes abortion services on professional (CMS-1500/837P) claims and explains coverage determination based on member benefits and emergency medical condition; applies to Premera and affiliated lines of business.

Policy Summary

PayerPremera Bluecross

PolicyAbortion procedure coding and coverage identification

Policy CodePolicy N/A

Change TypeScope expansioncoding updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit abortions on CMS-1500/837P professional claims using the listed CPT/HCPCS procedure codes and append modifier G7 when pregnancy resulted from rape/incest or is life-threatening.

SourceLink

POLICY UPDATE CHANGES

Broadened the policy to cover ALL abortions.

In the Policy section, added HCPCS abortion procedure codes for induced abortions.

In the Policy section, removed the last paragraph which indicated that other abortion procedures do not require a modifier.

~15abortion procedure codes enumerated in policy

G7 requiredmodifier requirement

Multiplereview history entries

Coverage Conditions and Rules

Coverage conditions and billing rules

Covered when ALL of the following conditions and billing rules are met:

note":"Submit abortions on CMS-1500 or 837P with the listed procedure codes","children":[]},{"operator":"all","text":"When the pregnancy resulted from rape or incest, or is certified by a physician as life‑threatening or endangering the life of the mother, append modifier G7 to the procedure code.","note":"Append modifier G7 for rape/incest or life‑threatening/endangering pregnancy","children":[]}]}

Abortion Procedure Codes

Abortion procedure CPT/HCPCSmixedCovered

59812	Treatment of incomplete abortion, any trimester, completed surgically
59820	Treatment of missed abortion, completed surgically; first trimester
59821	Treatment of missed abortion, completed surgically; second trimester
59830	Treatment of septic abortion, completed surgically
59840	Induced abortion, by dilation and curettage
59841	Induced abortion, by dilation and evacuation
59850	Induced abortion; by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines
59851	Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation
59852	Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed intra-amniotic injection)
59855	Induced abortion by one or more vaginal suppositories (Prostaglandin) with/without cervical dilation (e.g., Laminaria), including hospital admission and visits, delivery of fetus and secundines

1–10 of 18

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Policy Summary

PayerPremera Bluecross

PolicyAbortion procedure coding and coverage identification

Policy CodePolicy N/A

Change TypeScope expansioncoding updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit abortions on CMS-1500/837P professional claims using the listed CPT/HCPCS procedure codes and append modifier G7 when pregnancy resulted from rape/incest or is life-threatening.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Claim Submission & Coverage Determination Actions

Billing Rule

Claim submission and modifier requirement

Submit abortion services on a professional claim form (CMS-1500 paper claim or 837P electronic claim) using the listed CPT/HCPCS procedure codes; append modifier G7 when the pregnancy resulted from rape or incest or is certified by a physician as life‑threatening or endangering the life of the mother.

Use the CPT/HCPCS procedure codes enumerated in the policy when filing on CMS-1500 or 837P.
Append modifier G7 when pregnancy resulted from rape or incest or is life‑threatening/endangering to the life of the mother.

Prior Authorization

Coverage determined by member benefits and emergency medical condition

Coverage is determined by the member's benefit coverage and whether an emergency medical condition exists; services inconsistent with state or federal law will not be paid.

Verify member eligibility and benefit limits before rendering or billing services.
Claims for services that are inconsistent with applicable state or federal law may be denied and will not be paid.

Definitions and Modifier Guidance

Coverage of services

DefinitionCoverage is determined by member eligibility, benefit limits, application of the Plan's Medical Policy, and claims adjudication edits; reimbursement limited to provider scope of practice and applicable fee schedule.

Conditional factorsCoverage for abortion services requires member benefit coverage and consideration of whether an emergency medical condition exists.

Claims submissionAbortions should be submitted on professional claim forms (CMS-1500 or 837P) using the listed CPT/HCPCS procedure codes.

Payment limitsFinal payment is subject to standard claims adjudication edits and the Plan's professional or facility coding policies.

Provider restrictionsReimbursement is restricted to the provider's scope of practice and the applicable fee schedule.

Modifier G7

Modifier G7 meaningModifier G7 indicates the pregnancy resulted from rape or incest, or is certified by a physician as life‑threatening or endangering the life of the mother.

When to appendAppend modifier G7 to the abortion procedure code when the pregnancy is due to rape or incest, or is physician‑certified life‑threatening/endangering to the mother's life.

Claim impactClaims without the required G7 modifier for qualifying cases may be noncompliant with this policy and subject to audit or corrective action.