TRICARE Manuals - Display Chap 4 Sect 18.3 (RFP Baseline, Apr 6, 2021)

Surgery

Chapter 4

Section 18.3

Abortions

Issue Date: April 19, 1983

Authority: 32 CFR 199.2(b) and 32 CFR 199.4(e)(2)

Revision:

1.0 CPT CODES

59812 - 59857, 59866

2.0 HCPCS Codes

S0190, S0191, S0199

3.0 DESCRIPTION

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

4.0 POLICY

4.1 By law, abortions may not be cost-shared except:

4.1.1 In a case in which the pregnancy is the result of an act of rape or incest. A physician’s note in the patient’s medical record must support that it is the provider’s good faith belief, based on all of the information available to the provider, that the patient was the victim of rape or incest; or,

4.1.2 When the life of the mother would be endangered if the fetus were carried to term. Physician certification attesting that the abortion was performed because the mother’s life would have been endangered if the fetus were carried to term is required.

4.2 Services and supplies related to spontaneous, missed or threatened abortions and abortions related to ectopic pregnancies may be cost-shared.

4.3 All medically and psychologically necessary services and supplies related to a covered abortion are covered. This may include ultrasound performed prior to the abortion, pathology services, pregnancy tests, office visits, and any applicable requirements mandated by state and/or local laws. It also may include otherwise covered follow-up care, such as psychotherapy.

4.4 Drugs such as Mifeprex (Healthcare Common Procedure Coding System (HCPCS) code S0190) and misoprostol (HCPCS code S0191) and all associated services and supplies (HCPCS code S0199) may be cost-shared when the pregnancy is the result of an act of rape or incest.

5.0 Billing Procedures

5.1 G7 Modifier

To receive TRICARE reimbursement for abortions performed due to rape, incest or when the life of the mother is endangered if the fetus were carried to term, all claims, i.e., the CMS 1450 UB-04 and the CMS 1500 shall include the G7 modifier. The G7 modifier is defined as “the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening.”

5.2 Condition Codes

• AA - Abortion performed due to rape;

• AB - Abortion performed due to incest;

• AD - Abortion performed due to life endangering physical condition.

5.3 Outpatient Billing (Hospital Outpatient Departments (HOPDs) and Freestanding Ambulatory Surgery Centers (ASCs))

HOPDs and freestanding ASCs shall bill on the CMS 1450 UB-04 claim form. One of the condition codes in paragraph 5.2 and the G7 modifier is required on the UB-04 claim form in addition to one of the following Current Procedural Terminology (CPT) codes: 59840, 59841, 59850-59852, 59855-59857, 59866.

5.4 Professional Billing

Individual professional providers shall bill on the CMS 1500 claim form. One of the condition codes in paragraph 5.2 shall be listed in Form Locator (FL) 10d and the G7 modifier in FL24D. The claim shall include one of the following CPT codes: 59840, 59841, 59850-59852, 59855-59857, 59866.

6.0 TRICARE Encounter Data (TED)

All TED records submitted for covered abortions must include one of the following Special Processing Codes as appropriate:

• AE - Abortion performed due to rape;

• AF - Abortion performed due to incest; or

• AG - Abortion performed due to life endangering physical condition.

7.0 Education Requirements

The TRICARE Operations Manual (TOM), Chapter 11, Section 1 provides the contractors’ responsibility regarding education of providers and beneficiaries.

8.0 EXCLUSIONS

8.1 Services and supplies related to a noncovered abortion.

8.2 Abortion counseling, referral, preparation and follow-up for a non-covered abortion.

8.3 Abortions for fetal abnormality (e.g., anencephaly) or for psychological reasons (i.e., threatened suicide).

8.4 Selective reduction of multi-fetal gestations (CPT code 59866), except when the life of the mother would be endangered if the multi-fetal gestation was carried to term.

9.0 EFFECTIVE DATES

9.1 June 5, 1981, for beneficiaries of the Department of Health and Human Services (DHHS) (includes the Coast Guard, Commissioned Corps of the Public Health Service (PHS), and the National Oceanic and Atmospheric Administration (NOAA)).

9.2 December 29, 1981, for beneficiaries of the Department of Defense (DoD) (includes Army, Navy, Air Force and Marine Corps).

9.3 January 2, 2013, for abortions in a case in which the pregnancy is a result of an act of rape or incest, in accordance with Section 704 of the National Defense Authorization Act (NDAA) of 2013, Public Law 112-239.

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