- Presumptive Eligibility (PE)
- Diagnosis Coding
- Procedure Coding
- Freestanding Birth Centers
- CMS 1500 Paper Claim Reference Table
- Other Reproductive Health Care Related Services
- Family Planning, Sterilizations, Hysterectomies And Abortions
- Family Planning Services
- Voluntary Sterilizations
- Informed Sterilization Consent Requirements
- Other Reproductive Health Services
- Billing Information
- Timely Filing
- Obstetrical Care Revision Log
Presumptive Eligibility (PE)
Presumptive Eligibility (PE) provides medical assistance benefits to low-income pregnant women and their children prior to receiving approval for full Health First Colorado (Colorado's Medicaid program) benefits. This program improves benefit accessibility for pregnant women through the process known as PE.
PE allows a woman temporary Health First Colorado coverage for 60 days. PE members receive a PE card that identifies them as eligible for ambulatory medical services. Inpatient hospital (e.g., delivery) services are not a PE benefit. After the full eligibility determination process, Health First Colorado eligible members receive a Medical Identification Card (MIC).
Health First Colorado eligible pregnant women have continuous eligibility. Previously, the woman remained eligible throughout her pregnancy and until the end of the month in which the 60th day following the end of her pregnancy occurs. Beginning July 1, 2022, eligible pregnant women will have continuous eligibility until the end of the month in which the 365th day following the end of her pregnancy occurs (more details reported in the postpartum care section). Income changes during pregnancy do not affect eligibility. The infant has continuous eligibility until his or her first birthday.
Pregnant women are eligible for all Health First Colorado benefit services determined by their physician to be medically necessary. Pregnant women under age 21 are also eligible for Early and Periodic Screening Diagnosis and Treatment (EPSDT) services, including dental, vision care and EPSDT health checkups.
Women in the maternity cycle are exempt from co-payment. The provider must mark the co-payment indicator on the paper claim form or on the electronic format.
- Providers must be a CHP+ site to offer services
- Providers must verify CHP+ PE member eligibility through Colorado Access
Health First Colorado recognizes the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-10-CM) diagnostic coding reference. The following diagnoses are for reference only. See the ICD-10-CM for a full list of diagnosis codes. When required, use additional digits as indicated.
|Diagnosis Code||Description||Diagnosis Code||Description|
|Z32.00-Z32.02||Encounter for pregnancy test||O00.0-O00.9||Ectopic pregnancies|
|Z34.00-Z34.93||Encounter for supervision of normal pregnancy||O01.0-O02.0||Hydatidiform mole and other abnormal products of conception|
|O09.00-O09.93||Supervision of high-risk pregnancy||O02.1||Missed abortion (incomplete miscarriage)|
|O30.00-O30.93||Multiple gestation||O03.0-O03.9||Spontaneous abortion (miscarriage)|
|Z37.0 - Z37.9||Outcome of delivery||Z39.0 - Z39.2||Encounter for care and examination of mother immediately after delivery|
Billing for Global Obstetrical (OB) Care
Global Billing Requirements
Health First Colorado OB billing guidelines (as per the American Medical Association
(AMA) Current Procedural Terminology (CPT) guidelines and guidance from the American Congress of Obstetricians and Gynecologists (ACOG)) instructs that whenever possible, medical care provided during pregnancy, including antepartum (prenatal/PN) care, labor and delivery and the postpartum (PP) period should be billed using the global obstetrical CPT codes. Please note: CPT code descriptions are not contained in this manual. The descriptions are copyrighted by the American Medical Association (AMA). Providers should reference the current CPT coding manuals for procedure code descriptions.
The Global Obstetrical codes should be billed whenever the same group of practitioners (Same Group Physician and/or Other Health Care Professionals) all work towards and provide multiple components of OB care [antenatal: at least 4 visits prior to delivery, labor and delivery and postnatal (at least one PP visit) care]. Group practitioners should not itemize and bill OB services separately when a global code is available for use. Billing by the same group of providers is identified in interChange when: specified global OB billable services (those individual codes used for antenatal, labor & delivery and/or postnatal care) are billed utilizing the same billing provider group (identification number) and the same date of service or date span.
A complete or three-component Global OB service code should always be billed when: 1) at least 4 antenatal visits prior to delivery, 2) labor and delivery and 3) postnatal care (uncomplicated, until approximately six weeks postpartum) are reported and provided by the same provider group for the same date of service or date span. The date of delivery should be utilized when billing these global or partial OB codes. The three-component codes are listed below.
The complete Global OB CPT codes are identified as:
Exceptions to Global Billing Guidelines
The following examples are additional situations where itemization of OB services may be applicable.
Physicians from different group practice (non-affiliated practitioners) may provide and bill for individual components (that are generally included with global OB billing) when:
- The member transfers into or out of a physician or affiliated group practice and services provided do not meet the complete global OB service criteria.
- The member is referred to another non-group physician during her pregnancy
- The member has the delivery performed by another physician or other health care professional not associated with her regular physician or affiliated group practice
- The member terminates or miscarries her pregnancy
- The member changes insurers during her pregnancy.
Antepartum Care Only
CPT codes 59425 or 59426 should be billed when the practitioner or practitioners of the same group, will not be performing all 3 components of global OB care (4 or more antepartum visits, delivery and postpartum care). Only one antepartum care code is allowed to be billed per pregnancy. If 3 or fewer antepartum visits are performed, the appropriate E/M visit code should be billed, with the TH modifier appended to indicate that the visit is pregnancy-related but outside of the OB global billing code.
Antepartum Care Billed With Either Delivery or With Postpartum Care
There is not a comprehensive CPT code that describes antepartum care including delivery. Nor is there a comprehensive CPT code that describes antepartum care with postpartum care.
- When antepartum care and delivery are performed by the same group of practitioners, the provider must itemize and bill the appropriate antepartum code in addition to the appropriate delivery code. Antepartum and delivery codes should only be billed if postpartum care was not provided by the same group of practitioners.
- If postpartum care is provided along with antepartum care by the same group physician and/or other health care professional, but this group of practitioners does not perform the delivery, then the services should be itemized using the appropriate antepartum care code with the postpartum care code. Antepartum and postpartum codes should only be billed if delivery was not provided by the same group physician and/or other health care professional affiliated group (as identified by an identical Billing Provider Medicaid ID number). Hospital care, related to the delivery, is considered part of the delivery charge and is not considered part of postpartum care.
Postpartum Care Only
Postpartum care begins after the member is discharged from the hospital stay for delivery and extends throughout the postpartum period (ACOG guidelines consider the postpartum period (for global billing inclusion) to be six weeks following the date of the cesarean or vaginal delivery). The postpartum care only code (59430) should be reported by the same group physician and/or other health care professionals when postpartum services are provided but the delivery service (cesarean or vaginal) is NOT provided by this same group of practitioners.
Postpartum Care Coverage Period Extended
Effective July 1, 2022, Health First Colorado (and CHP+) members who are in a 60-day postpartum period or those delivering after July 1, 2022, will have their postpartum period coverage automatically extended to 365 days from their delivery date (coverage continues through the last day of the month in which the 365th day falls).
Whenever possible, medical care provided during pregnancy, labor and delivery, and the postpartum period should be billed using the global OB codes. The following CPT codes do not represent an exhaustive list of codes. Medical providers should consult the CPT codebook to ensure correct coding. Please refer to the American Medical Association (AMA) Current Procedural Terminology (CPT) guidelines and documents for specific definitions of listed CPT and CPT Category II codes.
Global Procedure Codes
|Global OB code||Units||NCCI edits Require Modifier (XU) when billing for Multiple Gestation||Prior Authorization Required|
|59400-59410 Vaginal Delivery: Comprehensive and Component Services|
|59410||1||59410 with 59409 use XU||No|
|59510-59515 Cesarean Section Delivery: Comprehensive and Component Services|
|59515||1||59515 with 59514 use XU||No|
|59610-59614 Vaginal Delivery after Prior Cesarean Section: Comprehensive and Component Services|
|59610||1||59610 with 59612 use XU||No|
|59614||1||59614 with 59612 use XU||No|
|59618-59622 Cesarean Section after attempted Vaginal birth/Prior C-Section: Comprehensive and Component Services|
|59618||1||59618 with 59620 use XU||No|
|59622||1||59622 with 59620 use XU||No|
|99201-99215 w/modifier TH||1||No|
Recording Provision (and Dates of Service) for Prenatal (Antepartem) and Postpartum Visits
Please refer to the American Medical Association (AMA) Current Procedural Terminology (CPT) documents for specific definitions of listed CPT and CPT Category II codes.
Effective June 1, 2023, Reporting the quality measures (for prenatal and postpartum care) will be required for Health First Colorado Medicaid agencies as a tool to monitor and help improve the quality of healthcare, health outcomes and for reporting to CMS.
This required OB billing change will be enforced for Fee-for-Service (FFS) providers submitting professional claims.
However, it is recommended that Federally Qualified Health Center (FQHC) and Rural Health Center (RHC) providers also follow these new billing guidelines to identify prenatal care visits when billing for labor and delivery (L&D) services (outside the normal encounter rate billing methodology) to accurately capture provision of these healthcare services and quality healthcare metrics. For postpartum visits, include the CPT Category II postpartum visit code on the regular encounter visit claim to capture and identify the postpartum care visit(s).
Providers are still required to bill the most appropriate global, bundled/partial or individual maternity/OB Common Procedural Terminology (CPT) codes (59400 – 59622) on claims. Using one of the CPT Category II codes to identify and document each prenatal and postpartum visit will be the required change in the obstetrical billing methodology.
This should be documented on the same claim as the global/partial maternity billing claim, or if only the prenatal or postpartum visits are provided (when billing the global/partial codes are not appropriate), then the CPT Category II prenatal and/or postpartum code(s) provided should also be included on that individual prenatal (antepartum) or postpartum claim.
|Prenatal and Postpartum Services provided with Global/Partial or Individual Maternal OB Service Care Codes (refer to AMA documents for specific code definitions)|
|0500F||0500F = use to report first prenatal encounter w health care professional|
|OR use 0501F, if more appropriate for Initial prenatal visit.|
|0501F||0501F = use when initial maternity related tests and measurements are recorded and documented|
|0502F||do not include for non-pregnancy related service visits|
|Postpartum to billed with Global/Partial/Individual OB Care|
These added CPT Category II “F” codes are for reporting purposes only and will not affect the claim reimbursement.
Providers will need to document the “F” codes below the identified maternity-related (global, partial or L&D) CPT code, on separate lines:
- The appropriately described CPT Category II code (0500F or 0501F, 0502F or 0503F for documenting the prenatal &/or postpartum care services. And,
- The date of service (DOS) for each of the prenatal visits and postpartum visits,
Claim with dates of service spanning 3/15/22 – 11/30/22 for Global OB code with 8 antepartum visits and 2 postpartum visits
- Line 1: Procedure code 59400 on Date of Delivery (DOS) 10/5/22 – Paid at the current web linked FFS Fee schedule
- Line 2: Procedure code 0500F or 0501F on DOS 3/15/22 – No charge line item
- Line 3: Procedure code 0502F on DOS 4/20/22 – No charge line item
- Line 4: Procedure code 0502F on DOS 5/25/22 – No charge line item
- Line 5: Procedure code 0502F on DOS 6/30/22 – No charge line item
- Line 6: Procedure code 0502F on DOS 7/20/22 – No charge line item
- Line 7: Procedure code 0502F on DOS 8/8/22 – No charge line item
- Line 8: Procedure code 0502F on DOS 8/26/22 – No charge line item
- Line 9: Procedure code 0502F on DOS 9/15/22 – No charge line item
- Line 10: Procedure code 0503F on DOS 11/4/22 – No charge line item
- Line 11: Procedure code 0503F on DOS 11/30/22 – No charge line item
Services Not Included in Global Reimbursement
- Unusual circumstances
- Conditions that are unrelated to the pregnancy or delivery
- Complications of pregnancy
- Certain adjunctive services
- Medical/Surgical services unrelated to the pregnancy
- Depression screens for pregnant and postpartum women
These services should be billed separately from (in addition to) global obstetrical care charges.
|Prenatal testing||Bill only for the testing or the portion of the testing performed by the provider
Use modifier -TC for technical component services only
Use modifier - 26 for professional services only
Use no modifier if professional and technical testing services are performed by the same provider
|Invasive or non-invasive prenatal testing, including ultrasound||Health First Colorado covers a maximum of two (2) ultrasounds for an uncomplicated or low-risk pregnancy. If the member's medical condition requires additional ultrasonography, medical records must be documented.|
|Clinical laboratory testing||
Providers must be CLIA certified
A prenatal obstetric panel must include tests for a complete blood count with differential, a hepatitis B surface antigen, a rubella antibody, syphilis and HIV testing, a red blood cell antibody screen, ABO blood typing, and Rh typing
Syphilis testing is a Colorado statutory requirement for the first trimester or at the first OB visit (testing independently or as included in the prenatal obstetric panel). Nationwide and in CO increased cases of syphilis and congenital syphilis have been reported so additional syphilis monitoring &/or testing for pregnant individuals at higher risk will be needed.
Laboratory testing other than routine chemical urinalysis and finger stick hematocrit.
|Adjunctive services||For example, Tracheloplasty/trachelorrhaphy, etc.|
|Initial antepartum visit||Use CPT E & M codes 99201-99215 for initial visit. Initial visit may involve additional time and attention.
The following represents possible diagnosis codes:
|Conditions requiring additional management||Billing for Multiple Infants:
To avoid claim denials and National Correct Coding Initiative (NCCI) edits on claims involving the delivery of multiple infants, additional information is required.
For Cesarean Deliveries: Bill only one CPT code and only one unit for the complete cesarean delivery, regardless of the number of babies delivered. Whether reporting for a: global delivery (59510 or 59618), delivery only (59514 or 59620), or delivery including post-partum care (59515 or 59622) only one cesarean procedure (with one incision) is being performed. Use the most accurate/complete procedure code which describes the antenatal care, delivery history, current delivery type, and any postnatal care provided for the current pregnancy.
For Vaginal Deliveries: bill multiple infants using the guidelines outlined below:
For the first infant (Baby A), use the most accurate and complete vaginal delivery diagnostic and procedure code. Choose the procedure code which best describes all services provided and considers delivery history, current delivery type, prenatal care and postnatal care.
Bill one unit of service for Baby A.
For the additional infant (Baby B), bill this infant on a separate line using one of the following delivery only codes: 59409 or 59612. Choose the code associated with the delivery history and delivery type you used for Baby A.
Include modifier '59' in the first position for Baby B. Use the delivery date as the date of service.
For Vaginal Deliveries followed by a Cesarean Delivery:
For a Vaginal Delivery of the first infant (Baby A): Use either code 59409 or 59612 for Baby A. Include modifier '59' in the first position for Baby A. Bill only one (1) unit of service.
For Cesarean Delivery of the second infant (Baby B): Use the most accurate/complete global cesarean procedure code that describes the antenatal and/or postnatal care or delivery only care provided for the current pregnancy. Use one of the following codes for Baby B: global delivery, delivery only, or delivery including post-partum care. Choose the Cesarean code associated with the same delivery history you used for Baby A: (59510 or 59515 with 59409) OR (59618, 59620 or 59622 with 59612). Bill one (1) unit of service for Baby B. Each infant should be listed on a separate line. Use the delivery date as the date of service.
NCCI Edit Requirements: A second modifier 'XU' is required for NCCI edits when the following code combinations are billed: 59410 with 59409, 59610 with 59612 or 59614 with 59612.
NCCI edits do not allow procedure code 59514 to be combined or billed with codes: 59400, 59409 or 50410.
Delivery Procedure Codes:
59400, 59410, 59409, 59610, 59614, 59612, 59510, 59515, 59514, 59618, 59622, 59620.
|Medical or surgical complications||Bill on an ongoing basis using the appropriate procedure code(s).
The diagnosis code must identify the complication or condition.
|Conditions unrelated to pregnancy||Medical or surgical services for conditions that are not related to pregnancy should be billed separately. Identify the condition requiring additional care. Services are subject to PCP referral.|
|Anesthesia||The delivery fee includes local, pudendal, and paracervical blocks by the delivering practitioner.
If the delivering practitioner begins block anesthesia for a vaginal delivery that subsequently requires a cesarean, separate charges may be submitted using the appropriate block code.
Anesthesia by a practitioner, other than the practitioner delivering the infant(s), must be billed by the provider who renders the service.
|Epidural anesthesia||Epidural anesthesia by a provider other than the delivering practitioner is a covered benefit. Document member contact time on the claim. Paper claims for more than 120 minutes (8 or more time units) of direct member contact epidural time require an attached copy of the anesthesia record. Electronic claims may be submitted (no attachments) but documents verifying extended direct member contact must be maintained and produced upon request.|
|Assistant surgeon at cesarean delivery||Modifier - 80 identifies assistant surgeon services. A family practitioner or certified nurse-midwife may bill as assistant surgeon at cesarean. Physician assistants, surgical assistants, and nurse practitioners may not bill as assistant surgeon. An assistant surgeon is not allowed on vaginal deliveries.|
|Treatment for high risk pregnant women||Women who would be high risk given physical health, psychosocial history, and current life stressors may be eligible for involvement in the Prenatal Plus (PN+) Program, a Health First Colorado benefit that provides a care team for women at higher risk of adverse birth outcomes. The service package includes a care coordinator, a dietitian, and a mental health professional. If you think the mother would be eligible, please visit the Prenatal Plus web page to find a provider near you.|
|Treatment for substance-abusing pregnant women||Substance abusing pregnant women may be eligible for involvement in Special Connections, a Health First Colorado-funded program for substance abuse treatment. The service package includes Risk assessment, case management, individual counseling, group counseling and health maintenance. Substance abusing pregnant women can refer themselves to Special Connections or be referred by a provider.|
|Emergency Medicaid-Special Instructions for Labor and Delivery Claims AND coverage when enrolled in BOTH: 1) Emergency Medicaid PLUS 2) the State-funded Family Planning Benefit Program||Labor & Delivery (L&D) is a benefit for recipients of Emergency Medicaid, but a sterilization is not normally a covered service for recipients ONLY enrolled in Emergency Medicaid. A sterilization procedure is not considered an emergency procedure. AND, if a sterilization is performed in conjunction with the L&D for a recipient ONLY enrolled under Emergency Medicaid, the coding and charges for the sterilization must be omitted from the claim and only the codes and charges for the delivery can be billed.
However, effective July 1, 2022, if an individual is also enrolled in the State-funded Family Planning benefit plan (with enrollment documentation in the claims system under Emergency Medicaid AND enrollment in the Family Planning benefit plan) contraceptives and sterilization procedures are considered covered services. For sterilization services, documentation following federal and state compliance guidelines for sterilization consent, which includes timely completion and member signature of the MED-178 sterilization consent form (30 days prior to sterilization procedure) are required and must be attached with claims.
|Immediate Post-Partum Long-Acting Reversible Contraceptives (IPP-LARCs)||
Effective January 1, 2020, IPP-LARC devices inserted in a DRG Hospital may be reimbursed at the fee schedule rate or the amount billed, whichever is less. Delivery DRG weights (540, 542 & 560) were reduced by .004 to allow for this separate payment.
The Inpatient Hospital Claim must group to APR-DRG 540, 542, or 560, and include:
The Outpatient Hospital Claim:
|In-Hospital Billing for Mother and Newborn||
For claims in which the mother's discharge date is on or after July 1, 2020:
Services for the mother and baby must be billed on separate claims under the identification number of each client per 10 CCR 2505-10 8.300.3.A.
For claims in which the mother's discharge date occurs prior to July 1, 2020:
Mother's and baby's charges (procedure and diagnosis codes) are billed on one claim as one stay while the mother is in the hospital. The interChange System cannot accept a baby's birth weight, the weight must be coded using an ICD-10 diagnosis code. Do not show nursery days in form locator (FL) 6. Nursery days are entered as units on a detail line but are not covered days that represent additional payment. There is no additional inpatient benefit for routine newborn hospitalization.
When the mother is not eligible for benefits, the baby's well-baby care charges may be billed under the following conditions:
Services may be billed on the mother's claim until the time the mother is discharged. Baby's charges, procedure and diagnosis codes related to the baby's extended stay, beginning with the mother's date of discharge through the baby's discharge, are billed separately from the mother's charges.
The baby requires its own Health First Colorado ID number. The admission date on the baby's hospital claim is the date of mother's discharge. Including a newborn/live (Z38, Z38X OR Z38XX) as a primary diagnosis on the baby's independent claim may cause the claim to be ungroupable and result in an appropriate denial. The primary diagnosis should reflect the reasons why the child remains in the hospital after mother leaves.
If the baby is transferred to a different hospital, the Health First Colorado benefits are still applicable. The baby's charges (procedure and diagnosis codes) must be billed separately by the receiving hospital.
Charges for a well newborn remaining in the hospital after the mother's discharge are not a Health First Colorado benefit (e.g., placement).
|Newborn Hearing and Metabolic Screenings||Costs associated with the Newborn Hearing Screening and the initial Newborn Metabolic Screening are included in the delivery DRG calculation or the birthing center facility payment. They may not be billed separately.
Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS) codes for the Newborn Hearing Screening cannot be billed for dates on or during the date span of the delivery stay. Refer to the Audiology Benefit Billing and Policy Billing Manual or the Laboratory Services Billing Manual for more information.
|Examination and evaluation of the healthy newborn||EPSDT Periodicity Guidelines recommend initial newborn screenings at 3-5 days and 2 weeks.|
|Routine or ritual circumcision||As of July 1, 2017, circumcision is available as a benefit of the program. The following CPT codes are being reimbursed 54150, 54160 or 54161. This change does not affect the CHP+ Program.|
Special Provider Considerations
|Enrolled Certified Nurse Midwives||May provide OB care in accordance with the Colorado Medical Practice Act. Certified Nurse Midwives submit claims in the same manner as physicians. Certified nurse-midwives may act as assistant surgeon at cesarean deliveries.|
|Certified Family Nurse Practitioners or Certified Pediatric Nurse Practitioners||Must be specifically identified and enrolled according to Health First Colorado provider enrollment policy. These non-physician practitioners do not require direct and personal supervision of an on-premises, licensed, Health First Colorado-enrolled physician and may receive direct reimbursement.|
|Physician assistants other nurse practitioners||These providers do not qualify for direct reimbursement. The provider number of the supervising physician must appear in the supervising provider field on the claim record. Physician assistants, surgical assistants, and nurse practitioners may not serve as assistant surgeons.|
Freestanding Birth Centers
A Birthing Center is licensed free-standing health care facility (not a hospital, nor attached to or located within a hospital) where care providers, including licensed Certified Nurse Midwives (CNMs) and physician (MDs/DOs) identified in Rule as clinical staff, provide family-centered, culturally competent and comprehensive prenatal, labor and delivery and postpartum care to healthy low-risk pregnant women and their newborns. Birth Center Health Care Facilities are licensed through the Colorado Department of Public Health and Environment (CDPHE).
Reimbursement for birth centers for services rendered to Health First Colorado-eligible members is only available to licensed (through CDPHE) freestanding birth centers (FSBC) that enroll with Health First Colorado as a Health First Colorado provider with a birth center specialty designation (58/116 = provider type/specialty type). Include a copy of your CDPHE license with your Health First Colorado provider enrollment application and request the specialty designation for FSBCs. Practitioners, such as certified nurse midwives, providing services at birth centers must also be enrolled as Health First Colorado providers and affiliated with the birth center under which claims are submitted.
In addition to the submission of claims for antepartum, delivery, and postpartum care (following global OB billing guidelines), freestanding birth centers can also submit claims for a birth center facility payment for that delivery and when a member must be transferred to a hospital.
|Description||Code(s)||Modifier - first position|
|Birth center payment||59899||HD|
The modifier included in the tables above and below are required for the claim to pay correctly. If 'HD' (women's program/service) is not included in the first position, the claim will pay incorrectly.
Occasionally, members are unable to deliver at the birth center and need to be transferred to a hospital. In these cases, a reduced birth center payment is available as is reimbursement for time spent with the member.
|Description||Code(s)||Modifier - first position||Modifier - second position|
|Transfer payment: Payment for costs incurred prior to transporting a member to a hospital||59899||HD||52|
In addition to the payment made for members who transfer, claims can be submitted for the time a midwife spends with the member prior to her transfer and for antepartum care.
|99215||Payment is based upon Health First Colorado's fee schedule.|
|99215 + 99354||Payment is based upon Health First Colorado's fee schedule.|
|99215 + 99354 + 99355
(1 unit of 99355 per each additional 30 minutes)
|Payment is based upon Health First Colorado's fee schedule.|
CMS 1500 Paper Claim Reference Table
The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.
|CMS Field Number & Label||Field is?||Instructions|
|1. Insurance Type||Required||Place an "X" in the box marked as Medicaid.|
|1a. Insured's ID Number||Required||Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.|
|2. Patient's Name||Required||Enter the member's last name, first name, and middle initial.|
|3. Patient's Date of Birth/Sex||Required||Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.
Place an "X" in the appropriate box to indicate the sex of the member.
|4. Insured's Name||Conditional||Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
|5. Patient's Address||Not Required|
|6. Patient's Relationship to Insured||Conditional||Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.|
|7. Insured's Address||Not Required|
|8. Reserved for NUCC Use||Not Required|
|9. Other Insured's Name||Conditional||If field 11d is marked "YES", enter the insured's last name, first name and middle initial.|
|9a. Other Insured's Policy or Group Number||Conditional||If field 11d is marked "YES", enter the policy or group number.|
|9b. Reserved for NUCC Use|
|9c. Reserved for NUCC Use|
|9d. Insurance Plan or Program Name||Conditional||If field 11D is marked "YES", enter the insurance plan or program name.|
|10a-c. Is patient's condition related to?||Conditional||When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.|
|10d. Reserved for Local Use|
|11. Insured's Policy, Group or FECA Number||Conditional||Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
|11a. Insured's Date of Birth, Sex||Conditional||Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.
Place an "X" in the appropriate box to indicate the sex of the insured.
|11b. Other Claim ID||Not Required|
|11c. Insurance Plan Name or Program Name||Not Required|
|11d. Is there another Health Benefit Plan?||Conditional||When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.|
|12. Patient's or Authorized Person's signature||Required||Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".
Enter the date the claim form was signed.
|13. Insured's or Authorized Person's Signature||Not Required|
|14. Date of Current Illness Injury or Pregnancy||Conditional||Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.
Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
|15. Other Date Not||Not Required|
|16. Date Patient Unable to Work in Current Occupation||Not Required|
|17. Name of Referring Physician||Conditional|
|17b. NPI of Referring Physician||Required||Required in accordance with Program Rule 8.125.8.A|
|18. Hospitalization Dates Related to Current Service||Not Required|
|19. Additional Claim Information||Conditional||TRANSPORTATION
When applicable, enter the word "TRANSPORT CERT" to certify that you have a transportation certificate or trip sheet on file for this service.
|20. Outside Lab?
|Conditional||Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.
Practitioners may not request payment for services performed by an independent or hospital laboratory.
|21. Diagnosis or Nature of Illness or Injury||Required||Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.
Enter applicable ICD-10 indicator.
|22. Medicaid Resubmission Code||Conditional||List the original reference number for resubmitted claims.
When resubmitting a claim, enter the appropriate bill frequency code in the left-hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
|23. Prior Authorization||Conditional||CLIA
When applicable, enter the word "CLIA" followed by the number.
Enter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.
|24. Claim Line Detail||Information||The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.
Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.
Each claim form must be fully completed (totaled).
Do not file continuation claims (e.g., Page 1 of 2).
|24A. Dates of Service||Required||The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.
Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
Global Obstetrical care
For global obstetrical care, the "From" and "To" dates of service must be entered as the date of delivery.
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
N4 - National Drug Codes
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
|24B. Place of Service||Required||Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
|24C. EMG||Conditional||Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.
If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
|24D.||Required||Enter the HCPCS procedure code that specifically describes the service for which payment is requested.
All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.
HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).
Only approved codes from the current CPT or HCPCS publications will be accepted.
Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
G7 – Termination of pregnancy resulting from rape, incest, or certified by physician as life-threatening.
|24E. Diagnosis Pointer||Required||Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.
At least one diagnosis code reference letter must be entered.
When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.
This field allows for the entry of 4 characters in the unshaded area.
|24F. $ Charges||Required||Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.
The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.
Submitted charges cannot be more than charges made to non-Health First Colorado-covered individuals for the same service.
Do not deduct Health First Colorado co-pay or commercial insurance payments from the usual and customary charges.
|24G. Days or Units||Required||Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.
Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period.
Anesthesia time begins when the anesthetist begins member preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefits or additional units are added for emergency conditions or the member's physical status.
The fiscal agent converts reported anesthesia time into fifteen-minute units. Any fractional unit of service is rounded up to the next fifteen-minute increment.
Codes that define units as inclusive numbers
Some services such as allergy testing define units by the number of services as an inclusive number, not as additional services.
|24H. EPSDT/Family Plan||Conditional||EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used
Family Planning (unshaded area)
If the service is Family Planning, such as for contraception or sterilization, enter "Y" for YES or "N" for NO in the bottom, unshaded area of the field.
|24I. ID Qualifier||Not Required|
|24J. Rendering Provider ID #||Required||In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.|
|25. Federal Tax ID Number||Not Required|
|26. Patient's Account Number||Optional||Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).|
|27. Accept Assignment?||Required||The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.|
|28. Total Charge||Required||Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.|
|29. Amount Paid||Conditional||Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.
Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
|30. Rsvd for NUCC Use|
|31. Signature of Physician or Supplier Including Degrees or Credentials||Required||Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.
Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider's name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
|32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
|Required||Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
|33. Billing Provider
Info & Ph #
|Required||Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
|33a- NPI Number||Required|
|33b- Other ID #||If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.|
OB Claim Example
OTHER REPRODUCTIVE HEALTH CARE RELATED SERVICES
Family Planning, Sterilizations, Hysterectomies and Abortions
|Billing Instruction Detail||Instructions|
Family Planning services are available for both female and male Health First Colorado members of child-bearing age, including minors. Women may receive family planning services during and after a pregnancy. Family planning services and supplies are identified and provided when the intent of the service is to prevent, delay or plan for a pregnancy. Family planning services include: examinations, treatment, sterilizations (excluding hysterectomies), all FDA-approved contraceptives/methods of birth control, basic fertility and reproductive system related education and family planning counseling. Prior authorization is not required for family planning services. When billing for family planning services, such as for contraception provision or sterilization procedures, always include the family planning (FP) modifier next to the appropriate procedure code on claims.
|Surgical sterilization||Voluntary sterilization is considered a family planning service (requiring the FP modifier with billing) and requires strict compliance with Federal informed consent regulations. Sterilization claims with attached documents should be submitted electronically. A copy of the CO Medicaid sterilization consent form MED-178, located on the Provider Forms web page under the Sterilization Consent Forms drop-down menu, must be attached to each related claim and completed according to the provider manual.
The male or female Health First Colorado member must be at least 21 years old on the date they sign the MED-178 and the form must be completed at least 30 days in advance of the procedure, but fewer than 180 days, unless emergency surgery or a premature delivery occurs (and informed consent (the MED-178 form) is signed by the client at least 30 days prior to the estimated date of delivery).
The surgeon must provide copies of the properly completed MED-178 to the assistant surgeon, anesthetist, and hospital. Claims without MED-178 documentation are denied.
Sterilization performed at the time of vaginal or cesarean delivery can be submitted electronically using the appropriate diagnosis, PCS and procedural sterilization codes and FP modifier with the required MED-178 form attached.If laparoscopic tubal ligation is performed, bill the base diagnostic laparoscopy on one detail line and the appropriate tubal ligation procedure code on a second detail line.
Refer to the MED-178 Instructions for completion and form located on the Provider Forms web page under the Sterilization Consent Forms drop-down menu.
|Treatment of HIV-infected persons||Treatment of HIV-infected persons with antiretroviral medications prescribed by a doctor is a Health First Colorado benefit. Medications include, but are not limited to, zidovudine (AZT), didanosine (ddI), and stavudine. Medications to treat HIV-related diseases must be FDA approved, listed on the drug formulary, and not classified as experimental. Most drugs do not require prior authorization. For questions on the status of drugs as a covered benefit, call your local pharmacy or Health First Colorado Provider Services.|
The service intent identified for family planning (FP) services including services to delay, prevent (such as contraceptive care and sterilization services) or to plan for a pregnancy.
The intent of the family planning service, such as a contraceptive pill prescription to prevent a pregnancy, must be documented in the client’s medical record. If the intended use of the contraceptive pill or other contraceptive, is not for pregnancy prevention, such as a contraceptive pill prescription for use to treat excess bleeding, this service/prescription logic should also be documented in the client’s medical record and the FP modifier should NOT be included next to the CPT/HCPCS code on the claim.
Services classified as eligible for family planning service use can be identified on the Fee-for-Service billing schedule with the FP modifier included as a billing option.
Examples of some of these service codes (when the FP intent is identified by the provider) are included below:
|Examples of Family Planning Service Codes|
|CPT/HCPFCS or Dx Code||CODE DESCRIPTION(S)||Modifier 1||Modifier 2|
|Contraceptives & Related Services|
|A4261||Cervical cap for contraceptive use||FP|
|A4266||Diaphragm for contraceptive use||FP|
|A4267||Condom contraceptive supply – male, each (available through clinician, not by prescription)||FP|
|A4268||Condom contraceptive supply – female, each ( available through clinician, not by prescription)||FP|
|A4269||Spermicide - (available through clinician, not by prescription)||FP|
|J1050||Hormonal Contraceptive Injection - Medroxyprogesterone acetate / Depo-Provera||FP|
|J7294||Hormonal Vaginal Ring, yearly vaginal system (Annovera)||FP|
|J7295||Hormonal Vaginal Ring, monthly vaginal system (Nuvaring, Etonogestrel-EE)||FP|
|J7296||Intrauterine device (IUD) – Hormonal - Kyleena / Long acting reversible contraceptive (LARC)||FP|
|J7297||IUD - Hormonal – Liletta -– LARC||FP|
|J7298||IUD - Hormonal - Mirena- LARC||FP|
|J7300||IUD - Copper T380-A - Paragard -– LARC||FP|
|J7301||IUD - Hormonal – Skyla - LARC||FP|
|J7304||Hormonal Contraceptive Patch||FP|
|J7307||Contraceptive Implant – Nexplanon -– LARC||FP|
|S4993||Emergency Contraceptive (EC) Pills||FP||U1|
Sterilization for the purpose of family planning is a benefit of Health First Colorado. Sterilization (i.e. tubal ligations, tubal occlusion and vasectomies) is intended to be a permanent, irreversible procedure to prevent consenting individuals from becoming pregnant or fathering a child. Submission of family planning sterilization claims should always include the family planning modifier (FP) and be submitted in accordance with the following procedures:
Examples of some of these sterilization service codes (when the FP intent is identified by the provider) are included below:
|CPT/HCPFCS or Dx Code||Modifier 1||Modifier 2|
Claims for sterilization procedures should be submitted electronically. A copy of the Health First Colorado sterilization consent form MED-178, located on the Provider Forms web page under the Sterilization Consent Forms drop-down menu, must be attached to each related claim for service including the hospital, anesthesiologist, surgeon, and assistant surgeon.
- The individual must be at least 21 years of age at the time the consent is obtained.
- The individual must be mentally competent. An individual who has been declared mentally incompetent by a federal, state or local court of competent jurisdiction for any purpose cannot consent to sterilization. The individual can consent if she has been declared competent for purposes that include the ability to consent to sterilization.
- The individual must voluntarily give "informed" consent as documented on the MED-178 consent form (see illustration) and specified in the "Informed Consent Requirements" described in these instructions.
- At least 30 days but not more than 180 days must pass between the date of informed consent and the date of sterilization with the following exceptions:
Emergency Abdominal Surgery
An individual may consent to sterilization at the time of emergency abdominal surgery if at least 72 hours have passed since he/she gave informed consent for the sterilization.
A woman may consent to sterilization at the time of a premature delivery if at least 72 hours have passed since she gave informed consent for the sterilization and the consent was obtained at least 30 days prior to the expected date of delivery.
The person may not be an "institutionalized individual".
- Involuntarily confinement or detention, under a civil or criminal statute, in a correctional or rehabilitative facility including a mental hospital or other facility for the care and treatment of mental illness.
- Confinement under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.
Unpaid or denied charges resulting from provider's failure to follow the required procedures in obtaining informed consent or failure to submit required documentation with the claim, may not be billed to the member.
Informed Consent Requirements
The person obtaining informed consent must be a professional staff member who is qualified to address all the consenting individual's questions concerning medical, surgical, and anesthesia issues.
Informed consent is considered to have been given when the person who obtained consent for the sterilization procedure meets all of the following criteria:
- Has offered to answer any questions that the individual who is to be sterilized may have concerning the procedure
- Has provided a copy of the consent form to the individual
- Has verbally provided all of the following information or advice to the individual who is to be sterilized:
- Advice that the individual is free to withhold or withdraw consent at any time before the sterilization is done without affecting the right to any future care or treatment and without loss or withdrawal of any federally funded program benefits to which the individual might be otherwise entitled
- A description of available alternative methods of family planning and birth control
- Advice that the sterilization procedure is considered to be irreversible
- A thorough explanation of the specific sterilization procedure to be performed
- A full description of the discomforts and risks that may accompany or follow the performing of the procedure including an explanation of the type and possible effects of any anesthetic to be used.
- A full description of the benefits or advantages that may be expected as a result of the sterilization
- Advice that the sterilization will not be performed for at least 30 days except in the case of premature delivery or emergency abdominal surgery
- Suitable arrangements have been made to ensure that the preceding information was effectively communicated to an individual who is blind, deaf, or otherwise handicapped.
- The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained.
- The consent form requirements (noted below) were met.
- Any additional requirement of the state or local law for obtaining consent was followed.
- Informed consent may not be obtained while the individual to be sterilized is:
- In labor or childbirth,
- Seeking to obtain or is obtaining an abortion, and/or
- Under the influence of alcohol or other substances that may affect the individual's sense of awareness.
MED-178 Consent Form Requirements
Evidence of informed consent must be provided on the MED-178 consent form. The MED-178 form is located on the Provider Forms web page under the Sterilization Consent Forms drop-down menu. The fiscal agent is required to assure that the provisions of the law have been followed before Health First Colorado payment can be made for sterilization procedures.
A copy of the MED-178 consent form must be attached to every claim submitted for reimbursement of sterilization charges including the surgeon, the assistant surgeon, the anesthesiologist, and the hospital or ambulatory surgical center. The surgeon is responsible for assuring that the MED-178 consent form is properly completed and providing copies of the form to the other providers for billing purposes.
Spanish forms are acceptable and are located on the Provider Forms web page under the Sterilization Consent Forms drop-down menu.
A sterilization consent form initiated in another state is acceptable when the text is complete and consistent with the Colorado form.
Completion of the MED-178 Consent Form
Refer to the MED-178 Instructions, located on the Provider Forms web page under the Sterilization Consent Forms drop-down menu. Information entered on the consent form must correspond directly to the information on the submitted Health First Colorado claim form.
Federal regulations require strict compliance with the requirements for completion of the MED-178 consent form or claim payment is denied. Claims that are denied because of errors, omissions, or inconsistencies on the MED-178 may be resubmitted if corrections to the consent form can be made in a legally acceptable manner.
Any corrections to the member's portion of the sterilization consent must be approved and initialed by the member.
The following procedure codes are examples used for sterilization:
The diagnosis code(s) associated:
Z30.2: Encounter for sterilization
Z98.51 or Z98.52: Use for sterilization follow-up evaluations
Male and Female surgical sterilization procedure codes and surgical methodologies (bilateral examples) are listed below. For additional surgical codes, refer to the ICD-10-PCS manual. If surgical procedures are unilateral (not bilateral) and surgery does not result in sterilization, utilize the appropriate right (RT) or left (LT) modifier with the procedure code on claims. When the unilateral procedure does not lead to complete sterilization, the Med 178 Sterilization Consent Form is not required.
If surgical procedures are unilateral (not bilateral) and surgery does not result in sterilization, utilize the appropriate right (RT) or left (LT) modifier with the procedure code on claims. When the unilateral procedure does not lead to complete sterilization, the MED-178 Sterilization Consent Form is not required.
Providers Billing on the CMS 1500 Claim Form
Use the appropriate procedure/diagnosis code from the recommended list above and the family planning modifier (FP).
Providers Billing on the UB-04 Claim Form Should Include:
- The appropriate procedure code (with the FP modifier)
- The ICD-10 Sterilization Diagnosis Code: Z30.2 (Encounter for sterilization) and,
- One ICD-10 PCS code (a 7-digit alpha-numeric code)
Sterilization ICD-10 Surgical Procedural Codes (PCSs) should be selected from the following methodologies.
Female ICD-10 PCS Sterilization Procedures:
Medical & Surgical=O / Female Reproductive System=U, with one of the following methodologies (5, 8, B, L, T)
Destruction=5 / Body Part (Ovaries, Bilateral = 2), (Fallopian Tubes, Bilateral=7) / Approach (0,3,4,8) / Device (Z) / Qualifier (Z) – i.e., OU520ZZ
Division=8 / Body Part (Ovaries, Bilateral = 2) / Approach (0,3,4) / Device (Z) / Qualifier (Z) – i.e., OU820ZZ
Excision=B / Body Part (Ovaries, Bilateral = 2), (Fallopian Tubes, Bilateral=7) / Approach (0,3,4,7, 8) / Device (Z) / Qualifier (X, Z) – i.e., OUB20ZX
Occlusion=L / Body Part (Fallopian Tubes, Bilateral=7) / Approach (0,3,4) / Device (C, D, Z) / Qualifier (Z) – i.e., OUL70CZ
Occlusion=L / Body Part (Fallopian Tubes, Bilateral=7) / Approach (7, 8) / Device (D, Z) / Qualifier (Z) – i.e., OUL77DZ
Resection=T / Body Part (Ovaries, Bilateral = 2), (Fallopian Tubes, Bilateral=7) / Approach (0,4,7, 8, F) / Device (Z) / Qualifier (Z) – i.e., OUT20ZZ
Male ICD-10 PCS Sterilization Procedures:
Medical & Surgical=0 / Male Reproductive System=V, with one of the following methodologies (5, B, L, T)
Destruction=5 (bilateral procedures) Vas Deferens=Q: 0V5Q0 / (Approach=0,3,4,8) / Device (Z) / Qualifier (Z) – i.e., 0V5Q8ZZ
Excision=B (bilateral procedures) Vas Deferens=Q: 0VBQ0 (Approach=0,3,4,8) / Device (Z) / Qualifier (X,Z) – i.e., 0VBQ8ZZ
Occlusion=L (bilateral procedures) Vas Deferens=Qs: 0VLQ0 (Approach=0,3,4,8) / Device=(C,D,Z) / Qualifier (Z) – i.e., 0VLQ8ZZ
Resection=T (bilateral procedures) Vas Deferens=Q: 0VTQ0 (Approach=0,4) / Device (Z) / Qualifier (Z) – i.e., 0VTQ4ZZ
Hysterectomy is a benefit of Health First Colorado when performed solely for medical reasons. Hysterectomy is not a family planning benefit nor a benefit of Health First Colorado if the procedure is performed solely for the purpose of sterilization, or if there was more than one purpose for the procedure and it would not have been performed but for the purpose of sterilization.
The following conditions must be met for payment of hysterectomy claims under Health First Colorado. These claims must be filed electronically.
- Prior to the surgery, the person who secures the consent to perform the hysterectomy must inform the member (and her representative, if in attendance) verbally and in writing that the hysterectomy will render the member permanently incapable of bearing children.
- The member and her representative, if any, must sign a Departmental Acknowledgement/Certification Statement for a Hysterectomy form as a written acknowledgment that she has been informed that the hysterectomy will render her permanently incapable of reproducing. The written Departmental Acknowledgment form must be signed and dated by the member, completed by the provider and submitted with the claim.
A written acknowledgment form from the member is not required if:
- The member is already sterile at the time of the hysterectomy, or
- The hysterectomy is performed because of a life-threatening emergency in which the practitioner determines that prior acknowledgment is not possible.
If the member’s acknowledgment is not required because of the one of the above noted exceptions, the practitioner who performs the hysterectomy must certify in writing on the Departmental Acknowledgement/Certification Statement form, one of the following:
- That the member was already sterile at the time of hysterectomy and stating the cause of the sterility; or
- That the member required the hysterectomy under a life threatening, emergency situation in which the practitioner determined that prior acknowledgment by the member was not possible. The statement must describe the nature of the emergency.
A copy of the member’s signed and dated Acknowledgment/Certification Statement form or the practitioner’s signed and dated Certification Statement form, as described above, must be attached to all claims submitted for hysterectomy services. The Acknowledgment/Certification Statement for a Hysterectomy form on which to report the required information is located under Claim Forms and Attachments > Women’s Health on the Provider Forms web page of the Department’s website. Providers may copy this form, as needed, for attachment to claim(s). The submitted form must be signed and dated by the practitioner performing the hysterectomy.
The surgeon is responsible for providing copies of the appropriate acknowledgment or certification to the hospital, anesthesiologist, and assistant surgeon for billing purposes. A copy of the written acknowledgment or practitioner’s statement must be attached.
Therapeutic legally induced abortions are a benefit of Health First Colorado when performed to:
- Save the life of the mother
- If the pregnancy is the result of a sexual assault (rape) and/or
- If the pregnancy is the result of incest.
A copy of the appropriate certification statement must be attached to all claims for legally induced abortions performed for one of the above three reasons.
Claims for spontaneous abortions (miscarriages), ectopic, or molar pregnancies do not require a certification statement to be attached when surgical procedures are utilized to treat the non-viable pregnancy situation. If the medications, mifepristone OR misoprostol (for a medication method) are utilized for treatment of non-viable pregnancy situations a certification statement form must be attached to all claims to identify the diagnostic condition related to mifepristone &/or misoprostol use.
The following procedure codes are appropriate for identifying induced abortions:
Diagnosis code: (decimal not required when billing)
Z33.2 - Encounter for elective termination of pregnancy, uncomplicated
Z33.2: is only available for reimbursement when the pregnancy is life-endangering (as certified by a physician) or is the result of a rape or incest, and proper supportive documentation is included with the claim.
Surgical procedure codes:
CMS 1500 Billing Requirements
Use the appropriate procedure/diagnosis code from the list above and the most appropriate modifier/condition code from the list below:
- G7 - Termination of pregnancy resulting from rape, incest, or certified by physician as life-threatening.
Claims must be submitted with the accurately completed required documentation identifying the affiliated condition associated with the pregnancy.
- AA - Abortion Due to Rape
- AB - Abortion Done Due to Incest
- AD - Abortion Due to Life Endangerment
Claims must be submitted with additional required documentation.
Abortion services must be performed or provided through a Health First Colorado- enrolled health care facility by a licensed practitioner (practicing within the scope of their license/practice), unless, in the judgment of the attending practitioner, a transfer to a Health First Colorado-enrolled health care facility endangers the life of the pregnant woman and there is no Health First Colorado-enrolled health care facility within a 30-mile radius of the place where the medical services are performed.
"To save the life of the mother" means:
The presence of a physical disorder, physical injury, or physical illness, which is a life-endangering physical condition caused by or arising from the pregnancy itself, as determined and certified by a physician, represents a serious and substantial threat to the life of the pregnant woman if the pregnancy is allowed to continue to term.
The presence of a psychiatric condition which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term.
All claims for services related to induced abortions to save the life of the mother must be submitted with the following documentation:
- Name, address, and age of the pregnant woman
- Gestational age of the unborn child
- Description of the medical condition which necessitated the performance of the abortion
- Description of services performed
- Name of the facility in which services were performed
- Date services were rendered
And, at least one of the following forms with additional supporting documentation that confirms life-endangering circumstances:
- Hospital admission summary
- Hospital discharge summary
- Consultant findings and reports
- Laboratory results and findings
- Office visit notes
- Hospital progress notes
The Certification Statement forms to report the required information is located in Claim Forms and Attachments, under Women's Health in the Provider Services Forms section of the Department's website. Providers may copy the appropriate form for attachment to claim(s). The submitted form documentation must be accurately completed and signed and dated by the practitioner performing the abortion service.
For psychiatric conditions lethal to the mother if the pregnancy is carried to term, the attending practitioner must:
- Obtain consultation with a physician specializing in psychiatry.
- Submit a report of the findings of the consultation unless the pregnant woman has been receiving prolonged psychiatric care.
Sexual assault (including rape) is defined in the Colorado Revised Statutes (C.R.S.) 18-3-402 through 405, 405.3, or 405.5. Incest is defined in C.R.S. 18-6-301. Providers interested in the legal basis for the following abortion policies should refer to these statutes.
All claims for services related to induced abortions resulting from sexual assault (rape) or incest must be submitted with the "Certification Statement for abortion for sexual assault (rape) or incest". This form is located in Claim Forms and Attachments, under Women's Health in the Provider Services Forms section of the Department's website. This form must:
- Be accurately completed and signed and dated by the practitioner performing the induced abortion AND
- Indicate if the pregnancy resulted from sexual assault (rape) and/or incest. Reporting the incident to a law enforcement or human services agency is not mandated.
No additional documentation is required.
The practitioner performing the abortion is responsible for providing the required documentation to other providers (facility, anesthetist, etc.) for billing purposes.
If mifepristone (a medication method) is utilized for treatment of a miscarriage or a non-viable pregnancy situation, a certification statement form must be attached to all claims to identify the diagnostic condition related to mifepristone use.
Ectopic and Molar Pregnancies
Surgical and/or medical treatment of pregnancies that have terminated spontaneously
(miscarriages) and treatment of ectopic and molar pregnancies are routine benefits of Health First Colorado. Claims for treatment of these conditions do not require additional documentation (unless mifepristone and/or misoprostol are utilized). The claim must indicate a diagnosis code that specifically demonstrates that the termination of the pregnancy was not performed as a therapeutic legally induced abortion.
The following diagnosis codes are appropriate for identifying conditions that may properly be billed for Health First Colorado reimbursement.
|O02.0-O02.9||Other abnormal products of conception|
|O02.1||Missed Abortion (incomplete miscarriage)|
|O08.0-O08.9||Complications following ectopic and molar pregnancy|
The following CPT procedure codes may be submitted for covered abortion and abortion-related services.
|58120||Dilation & Curettage, diagnostic and/or therapeutic (non-obstetrical)|
|59100||Hysterotomy, abdominal (For Removal of Hydatidiform Mole, Abortion)|
|59812-59830||Medical and Surgical Treatment of Miscarriage|
Fetal Anomalies Incompatible with Life Outside the Womb
Therapeutic abortions performed due to fetal anomalies incompatible with life outside the womb are not a Health First Colorado benefit.
For more information on timely filing policy, including the resubmission rules for denied claims, refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu.
Obstetrical Care Manual Revision Log
|Revision Date||Addition/Changes||Made by|
|12/1/2016||Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive.||HPE (now DXC)|
|12/27/2016||Updates based on Colorado iC Stage II Provider Billing Manuals Comment Log v0_2.xlsx||HPE (now DXC)|
|1/10/2017||Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx||HPE (now DXC)|
|1/19/2017||Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx||HPE (now DXC)|
|1/26/2017||Updates based on Department 1/20/2017 approval email||HPE (now DXC)|
|5/22/2017||Updates based on Fiscal Agent name change from HPE to DXC||DXC|
|1/2/2018||Supplemental Qualifier addition - instructions for reporting an NDC||DXC|
|6/27/2018||Edited all, addition of more global OB billing specifics and slight rearrangement of information regarding Other reproductive health care services.||HCPF|
|6/28/2018||Removal of duplicated and superfluous verbiage, restoring links||HCPF|
|7/2/2018||Minor style and consistency edits||DXC|
|12/21/2018||Clarification to signature requirements||HCPF|
|3/18/2019||Clarification to signature requirements||HCPF|
|1/15/2020||Converted to web page||HCPF|
|9/14/2020||Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table||HCPF|
|4/13/2021||Changes have been made due to required claim system changes (ClaimsXTN). Additional billing information, such as billing for Immediate post-partum LARCs and separation of maternal & infant billing has been added.||HCPF|
|8/24/2022||2021 Legislative bill implementations have required billing manual and system changes for maternal postpartum care, family planning services and abortion services||HCPF|
|1/12/2023||Restored Hysterectomy section||HCPF|
|3/31/2023||Added OB billing change instructions for required reporting of prenatal and postpartum visits. Provided clarifying instructions for sterilizations provided to new family planning eligibility groups that are also enrolled for labor and delivery services and added some clarifying edits.||HCPF|
|9/15/2023||Cleaned up alignment in tables and verbiage regarding in-hospital billing for mother and newborn||HCPF|