Highmark Commercial Medical Policy in Delaware
Section: Surgery
Number: S-2
Version: 002
Topic: Abortions
Effective Date: January 1, 2012
Issued Date: June 17, 2013
Date Last Reviewed: 06/2013

General Policy Guidelines

Indications and Limitations of Coverage

Providers submitting claims for non-elective induced abortions should indicate by use of the appropriate procedure code (59840-59857, 59866, S0190, S0191, S0199, S2260) 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.

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).

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; or
  3. When abortion is performed in a case of pregnancy which is the result of incest.

Procedure Codes

598125982059821598305984059841
598505985159852598555985659857
59866S0190S0191S0199S2260S2265
S2266S2267    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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.

EPO/PPO Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

HMO/POS Guidelines

Refer to General Policy Guidelines

Publications

References

Abd-El-Maeboud KH, Ghazy A, Ibrahim A, et al. Vaginal acidity enhancement with a 3% acetic acid gel prior to misoprostol treatment for pregnancy termination in the midtrimester. Int J Gynaecol Obstet. 2012 Sep 11[Epub ahead of print].

Pallitto CC, García-Moreno C, Jansen HA, et al. Intimate partner violence, abortion, and unintended pregnancy: Results from the WHO Multi-country Study on Women's Health and Domestic Violence. Int J Gynaecol Obstet. 2012 Sep 5. [Epub ahead of print]

Adler AJ, Filippi V, Thomas SL, et al. Quantifying the global burden of morbidity due to unsafe abortion: Magnitude in hospital-based studies and methodological issues. Int J Gynaecol Obstet. 2012 Sep;118 Suppl 2:S65-77.

Shellenberg KM, Tsui AO. Correlates of perceived and internalized stigma among abortion patients in the USA: An exploration by race and Hispanic ethnicity. Int J Gynaecol Obstet. 2012 Sep;118 Suppl 2:S152-9.

Goldstone P, Michelson J, Williamson E.et al. Early medical abortion using low-dose mifepristone followed by buccal misoprostol: a large Australian observational study. Med J Aust. 2012 Sep 3;197(5):282-6.

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[Version 001 of S-2]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

ICD-10 Diagnosis Codes

Glossary




This policy is intended to document those medical guidelines used by Highmark Blue Cross Blue Shield Delaware for the purpose of coverage and reimbursement determinations under Highmark Blue Cross Blue Shield Delaware health benefit plans. These guidelines are appropriate for the majority of individuals with a particular disease, illness, or condition; however, each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Highmark Blue Cross Blue Shield Delaware retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark Blue Cross Blue Shield Delaware. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.