Obstetrical Care Billing Manual

• Presumptive Eligibility (PE)
• Diagnosis Coding
  • Billing for Obstetrical (OB) Care
    • Global Obstetrics Billing
    • Exceptions to Global Billing Guidelines
    • Prenatal Care Only
    • Labor and Delivery (L&D) Only 
    • Postpartum Care Only
    • Prenatal Care and Delivery 
    • Labor and Delivery and Postpartum Care  
  • Global, Partial/Bundled and Individual Service Procedure Codes
  • Services Not Included In Global Reimbursement
  • Separate Procedures
  • Special Provider Considerations
• Freestanding Birth Centers
  • Provider Enrollment
• CMS 1500 Paper Claim Reference Table
  • OB Claim Example
• Other Reproductive Health Care Related Services
• Family Planning, Sterilizations, Hysterectomies and Abortions
• Family Planning Services
  • Voluntary Sterilizations
    • General Requirements
    • Emergency Abdominal Surgery
    • Premature Delivery
  • Informed Sterilization Consent Requirements
    • MED-178 Consent Form Requirements
    • Completion Of The MED-178 Consent Form
    • Providers Billing on the CMS1500 Claim Form
    • Providers Billing on the UB-04 Claim Form
  • Other Reproductive Health Services
    • Hysterectomies
    • Abortions
    • Induced Abortions
    • CMS 1500 Requirements
    • UB-04 Claim Form Requirements
    • Induced Abortions to Save the Life of the Mother
    • Induced Abortions when Pregnancy is the Result of Sexual Assault (Rape) or Incest
    • Spontaneous Abortion (Miscarriage)
    • Ectopic and Molar Pregnancies
    • Fetal Anomalies Incompatible with Life Outside the Womb
• Billing Information
• Gender-Specific Procedures
• Timely Filing
• Obstetrical Care Revision Log

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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 Child Health Plan Plus (CHP+) site to offer services.
• Providers must verify CHP+ PE member eligibility through Colorado Access.

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Diagnosis Coding

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. Refer to the ICD-10-CM for a full list of diagnosis codes. When required, use additional digits as indicated.

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Billing for Obstetrical (OB) Care

Health First Colorado uses a bundled payment for professional services provided during the perinatal period, including prenatal care, labor and delivery and postpartum care. Pregnancies, excluding high-risk pregnancies, are reimbursed through a global payment rate. There are certain circumstances where providers may bill a partial global payment. 

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Global Obstetrics Billing

The global obstetrics (OB) code must be billed whenever one (1) practitioner or practitioners of the same group provide all components of the members obstetrical care, including four (4) or more prenatal visits, labor and delivery and postpartum care. The number of prenatal visits may vary from member to member. However, if more than four (4) prenatal visits, labor and delivery and postpartum care are provided, ALL pregnancy related visits (excluding inpatient hospital visits for complications of pregnancy) must be billed under the global OB code.   

The date of delivery must be reported when billing these global OB codes.  

The complete global OB CPT codes are identified as:  

• 59400  
• 59510 
• 59610 
• 59618 

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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 in 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 their pregnancy.  
• The member has the delivery performed by another physician or other health care professional not associated with their regular physician or affiliated group practice.  
• The member terminates or miscarries their pregnancy.  
• The member changes insurers during their pregnancy.  
   

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Prenatal Care Only 

Prenatal care only codes should be billed when the practitioner or practitioners of the same group will NOT be performing all three (3) components of global OB care. Only one (1) prenatal care code is allowed to be billed per pregnancy.  

• When less than four (4) prenatal visits are performed, bill the appropriate E/M codes for the visits. The appropriate E&M visit code must be billed with the TH modifier added to indicate that the visit is pregnancy-related, but outside of the OB global billing code. 
• For four (4)-six (6) prenatal visits, bill CPT code 59425 with the appropriate 0500F or 0501F code identifying the initial date of service (DOS).  
• For seven (7) or more prenatal visits, bill CPT code 59426 with appropriate 0500F or 0501F identifying the initial DOS.  

The DOS used for billing the prenatal CPT code must be the same DOS reported for the first prenatal visit which is identified by the appropriate Category II CPT “F” code. 
 

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Labor and Delivery (L&D) Only 

Delivery begins on the date of initial hospitalization for delivery and extends through the date in which the member is released from the hospital. Hospital care related to the delivery is considered part of the delivery charge and is NOT considered part of postpartum care.  

• For vaginal delivery only, bill CPT code 59409.
• For C-section delivery only, bill CPT code 59514.
• For vaginal birth after C-section (VBAC), bill code 59612. 
• For C-section after attempted VBAC delivery only, bill code 59620.
   

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Postpartum Care Only 

Postpartum care begins after the patient is discharged from the hospital stay for delivery and extends throughout the postpartum period.  

• For postpartum care only, bill code 59430 with the appropriate 0503F, identifying the initial DOS.

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Prenatal Care and Delivery 

There is not a comprehensive CPT code that describes prenatal care, including delivery. Therefore, when prenatal care and delivery are performed, the provider must bill the appropriate prenatal code and either 0500F or 0501F CPT code and the appropriate delivery code. Prenatal and delivery codes should only be billed if postpartum care was NOT provided. Hospital care related to the delivery is considered part of the delivery charge and is NOT considered part of postpartum care. 

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Labor and Delivery and Postpartum Care  

Providers may submit an interim claim for partial global payment when prenatal and labor and delivery services have been rendered. If a postpartum visit is subsequently provided, the provider must void the partial global claim and submit a new claim using the appropriate global codes, including prenatal, labor and delivery and postpartum services. This claim submission should ONLY be billed after the postpartum visit has been provided. The global OB codes should NOT be billed until the postpartum visit has been provided.

Partial Global billing refers to maternity care not managed by a single provider or group practice. Billing for partial global services may occur if: 

• A member transfers into or out of a physician or group practice 
• A member is referred to another physician during the pregnancy  
• A member has the delivery performed by another physician or other health care professional not associated with their physician or group practice.
• A member terminates or miscarries the pregnancy.
• A member changes insurers during the pregnancy.
• The physician provides only partial services instead of the entire global OB services, to bill for that portion of care only.

Providers must use the appropriate codes for prenatal-only, postpartum-only, labor and delivery only or labor and delivery and postpartum services only.  

When a provider performs the delivery and postpartum care, and did NOT perform the prenatal care, the appropriate delivery and postpartum code should be billed.  

• For vaginal delivery including postpartum care, bill code 59410 with the appropriate 0503F CPT code identifying the initial DOS for postpartum care. 
• For C-section delivery including postpartum care, bill code 59515 with the appropriate 0503F CPT code with identifying initial DOS for postpartum care. 
• For VBAC including postpartum care, bill code 59614 with the appropriate 0503F CPT code with identifying initial DOS for postpartum care.  
• For C-section after attempted VBAC including postpartum care, bill code 59622 with appropriate 0503F CPT code with identifying initial DOS for postpartum care. 
   

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Global, Partial/Bundled and Individual Service Procedure Codes

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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

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Separate Procedures

These services should be billed separately from (in addition to) global obstetrical care charges.

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Special Provider Considerations

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Freestanding Birth Centers

A Birthing Center is licensed free-standing healthcare 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 (6 CCR 1011-1 Chapter 22) 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 & Environment (CDPHE) and regulated through statutory authority identified in sections 25-1.5-103 & 25-3-100.5, et seq., C.R.S. and C.R.S.12-30-118.

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Provider Enrollment

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 or Direct-Entry/Certified Professional midwives (DEM/CPM) 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.

Billing Requirements

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.

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.

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.

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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.

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OB Claim Example

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Other Reproductive Healthcare-Related Services

Family Planning, Sterilizations, Hysterectomies and Abortions

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Family Planning 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:

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Voluntary Sterilizations

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:

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General Requirements

Claims for sterilization procedures should be submitted electronically. A copy of the Health First Colorado Consent to Sterilization - MED 178 Form, 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 Consent to Sterilization - MED 178 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.

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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.

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Premature Delivery
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".

Institutionalized includes:

• 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.

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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.

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MED-178 Consent Form Requirements
Evidence of informed consent must be provided on the Consent to Sterilization - MED 178 Form 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 Consent to Sterilization - MED 178 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.

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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 Consent to Sterilization - MED 178 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.

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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).

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Providers Billing on the UB-04 Claim Form Should Include

1. The appropriate procedure code (with the FP modifier)
2. The ICD-10 Sterilization Diagnosis Code:  Z30.2 (Encounter for sterilization) and,
3. One (1) 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 and Surgical=O / Female Reproductive System=U, with one (1) 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 and Surgical=0 / Male Reproductive System=V, with one (1) 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
 

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Other Reproductive Health Services

Hysterectomies

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 (1) 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 the person's representative, if in attendance) verbally and in writing that the hysterectomy will render the member permanently incapable of bearing children.
• The member and the person's representative, if any, must sign a Departmental Acknowledgement/Certification Statement for a Hysterectomy form as a written acknowledgment that the member has been informed that the hysterectomy will render the member 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 (1) of the above noted exceptions, the practitioner who performs the hysterectomy must certify in writing on the Departmental Acknowledgement/Certification Statement form, one (1)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 on the Provider Forms web page under Claim Forms and Attachments > Women’s Health. 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.

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Abortions

Induced Abortions
Therapeutic legally induced abortions are a benefit of Health First Colorado when performed to:

1. Save the life of the mother
2. If the pregnancy is the result of a sexual assault (rape) and/or
3. 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 (1) of the above three (3) 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 and/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:

• 10A07Z6
• 10A07ZZ
• 10A07ZW
• 10A07ZX
• 10A00ZZ
• 10A08ZZ

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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.

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 UB-04 Claim Form Requirements
Use the appropriate procedure/diagnosis code and the most appropriate condition code from the list below:

• 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.

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Induced Abortions to Save the Life of the Mother
Every reasonable effort to preserve the lives of the mother and unborn child must be made before performing an induced abortion.

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 (1) 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 for Abortion for Sexual Assault (Rape) or Incest Form is located on the Provider Forms web page under Claim Forms and Attachments > Women's Health. 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.

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Induced Abortions when Pregnancy is the Result of Sexual Assault (Rape) or Incest

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 Form located on the Provider Forms web page under Claim Forms and Attachments > Women's Health. 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.

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Spontaneous Abortion (Miscarriage)

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.

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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.

The following CPT procedure codes may be submitted for covered abortion and abortion-related services.

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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.

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Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.

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Gender-Specific Procedures

Many procedures that are restricted to a member's assigned sex at birth will still be medically necessary after legally changing their gender. Follow the billing guidance below if a gender-specific procedure conflicts with the member's identified gender in the Colorado Benefits Management System (CBMS):

• CMS-1500/837P Claims: Enter the KX modifier on the appropriate line items.
• UB-04/837I Claims: Providers should enter condition code 45 to indicate a procedure is medically necessary despite a gender conflict.

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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Obstetrical Care Manual Revision Log

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