Billing for Abortion Services

100.1 - Billing for Abortion Services (Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16) Effective October 1, 1998, abortions are not covered under the Medicare program except for instances where the pregnancy is a result of an act of rape or incest; or the woman suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused by the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed. A. - "G" Modifier The "G7" modifier is defined as "the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening." Beginning July 1, 1999, providers should bill for abortion services using the new Modifier G7. This modifier can be used on claims with dates of services October 1, 1998, and after. CWF will be able to recognize the modifier beginning July 1, 1999. B. - A/B MAC (A) Billing Instructions 1. Hospital Inpatient Billing Hospitals use bill type 11X. Medicare will pay only when one of the following condition codes is reported: Condition Code Description AA Abortion Performed due to Rape AB Abortion Performed due to Incest AD Abortion Performed due to life endangering physical condition With one of the following: If ICD-9-CM Is Applicable: • an appropriate ICD principal diagnosis code that will group to DRG 770 (Abortion W D&C, Aspiration Curettage Or Hysterotomy) or • an appropriate ICD principal diagnosis code and one of the following ICD-9-CM operating room procedure that will group to DRG 779 (Abortion W/O D&C):69.01, 69.02, 69.51, 74.91. If ICD-10-CM is applicable, one of the following ICD-10-PCS codes are used: ICD-10- PCS code Description 10A07ZZ Abortion of Products of Conception, Via Natural or Artificial Opening 10A08ZZ Abortion of Products of Conception, Via Natural or Artificial Opening Endoscopic 10D17ZZ Extraction of Products of Conception, Retained, Via Natural or Artificial Opening 10D18ZZ Extraction of Products of Conception, Retained, Via Natural or Artificial Opening Endoscopic 10A07ZZ Abortion of Products of Conception, Via Natural or Artificial Opening 10A08ZZ Abortion of Products of Conception, Via Natural or Artificial Opening Endoscopic 10A00ZZ Abortion of Products of Conception, Open Approach 10A03ZZ Abortion of Products of Conception, Percutaneous Approach 10A04ZZ Abortion of Products of Conception, Percutaneous Endoscopic Approach Providers must use ICD-9-CM codes 69.01 and 69.02 if ICD-9-CM is applicable, or, if ICD- 10-CM is applicable, the related 1CD-10-PCS codes to describe exactly the procedure or service performed. The A/B MAC (A) must manually review claims with the above ICD-9-CM/ICD-10-PCS procedure codes to verify that all of the above conditions are met. 2. Outpatient Billing Hospitals will use bill type 13X and 85X. Medicare will pay only if one of the following CPT codes is used with the "G7" modifier. 59840 59851 59856 59841 59852 59857 59850 59855 59866 C. - Common Working File (CWF) Edits For hospital outpatient claims, CWF will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with the "G7" modifier and one of the above CPT codes. For hospital inpatient claims, CWF will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with one of the above inpatient procedure codes. D. - Medicare Summary Notices (MSN)/Explanation of Your Medicare Benefits Remittance Advice Message If a claim is submitted with one of the above CPT procedure codes but no "G7" modifier, the claim is denied. The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3. Group Code: CO CARC: 272 RARC: N/A MSN: 21.21