Providers submitting claims for non-elective induced abortions should indicate by use of the appropriate procedure code (59840-59857, 59866, S0190, S0191, S0199, S2260, S2262) and the modifier G7 (Pregnancy resulted from rape or incest or pregnancy certified by a physician as life threatening) to indicate that the criteria for performing an abortion were met.

Induced abortions for other than those reasons listed above will be considered elective and should be reported under codes 59840-59857, 59866, S0190, S0191, S0199, S2260, S2265, S2266, and S2267.

Obtaining an induced abortion using Mifepristone (i.e., the abortion pill, RU-486) (S0190, S0191, S0199) requires several visits to the doctor. On the first visit, information and counseling are provided. After a mandatory 24 hour waiting period, the patient may then return to receive an appropriate oral dose of Mifepristone (S0190). On the third visit - usually two days later - an appropriate dose of Misoprostol (S0191) is provided. A follow-up visit is generally scheduled approximately 12 days after the ingestion of Misoprostol to confirm that the pregnancy has been terminated. The allowance for S0199 includes the 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 complete abortion) except drugs. Drugs should be reported separately, using S0190 for Mifepristone and S0191 for Misoprostol.

Treatment of a spontaneous abortion, any trimester, which has been treated medically should be reported under code 99201-99233, as appropriate.

Abortions, whether induced (non-elective or elective) or spontaneous, are reimbursable for those contracts providing medical/surgical coverage. Exceptions are those group contracts which choose to exclude coverage for elective abortions or are required by law to consider elective abortions ineligible for payment.

The pre-existing clause in all non-group agreements will be applied to all abortions.  Eligibility for abortions will be predicated upon the date of conception and the effective date of the member's agreement.

Description

Abortion is defined as the expulsion or extraction from the uterus of the products of conception prior to the stage of viability at about 20 weeks of gestation (fetus weighs less than 500 g). Abortions are elective or non-elective. There are three classifications of non-elective abortions: spontaneous (59812-59821), septic (59830), and induced (59840-59857, 59866, S0190, S0191, S0199, S2260, S2262).

Non-elective induced abortions are defined as follows:

1. When abortion is necessary to avert the death of the mother;
   
   
2. When abortion is performed in a case of pregnancy which is the result of rape reported within 72 hours to a law enforcement agent; or
   
   
3. When abortion is performed in a case of pregnancy which is the result of incest which is reported within 72 hours from the date when the female first learns she is pregnant.

Benefits are not provided for services or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or if the pregnancy is the result of an act of rape or incest.

PRN References

04/1996, Federal Employee Health Benefits plans place new limits on coverage of abortions

08/1997, Abortion coverage linked to customers' wishes and state laws

10/1999, New modifier for non-elective abortions

12/2000, Coverage available for FDA approved Mifepristone for early abortion

02/2002, New codes available for induced abortions using Mifepristone