TRICARE Manuals - Display Chap 4 Sect 18.3 (Change 94, Jan 5, 2022)

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: C-86, July 14, 2021

1.0 CPT PROCEDURE CODE RANGE

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, the contractor shall not cost-share abortions except:

4.1.1 In a case in which the pregnancy is the result of an act of rape or incest. The contractor shall ensure a physician’s note in the patient’s medical record supports 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 by carrying the fetus to term. The contractor shall require a physician certification attesting that the abortion was performed because the mother’s life would have been endangered by carrying the fetus to term.

4.2 The contractor shall cost-share services and supplies related to spontaneous, missed or threatened abortions and abortions related to ectopic pregnancies.

4.3 The contractor shall cover all medically and psychologically necessary services and supplies related to a covered abortion. The contractor shall include ultrasounds performed prior to the abortion, pathology services, pregnancy tests, office visits, and any applicable requirements mandated by state or local laws. The contractor shall also include otherwise covered follow-up care, such as psychotherapy.

4.4 The contractor shall cost-share drugs such as Mifeprex (HCPCS S0190) and misoprostol (HCPCS S0191) and all associated services and supplies (HCPCS S0199) 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, the contractor shall ensure all claims; (i.e., the CMS 1450 UB-04 and the CMS 1500) 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

To receive TRICARE reimbursement for abortions performed due to rape, incest or when the life of the mother is endangered by carrying the fetus to term, the contractor shall ensure all claims; (i.e., the CMS 1450 UB-04 and the CMS 1500) include one of the following 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))

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

5.4 Professional Billing

The contractor shall ensure individual professional providers bill using the CMS 1500 claim form. The contractor shall require one of the condition codes in paragraph 5.2 be listed in FL 10d and the G7 modifier in FL24D. The contractor shall ensure the claim includes one of the following CPT procedure codes: 59840, 59841, 59850-59852, 59855-59857, 59866.

6.0 TRICARE Encounter Data (TED)

The contractor shall ensure all TED records for covered abortions 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’ responsibilities regarding provider and beneficiary education.

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 procedure 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, Marine Corps, and Space Force).

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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