Reproductive Health Care Billing Manual

Reproductive Health Care and Related Services

• Family Planning and Family Planning-Related Services
  • Covered Services
    • Non-covered services
  • Voluntary Sterilizations
    • Requirements for Sterilization Procedures
  • Informed Sterilization Consent Requirements
    • MED-178 Consent Form Requirements
    • Exceptions
  • Basic Fertility Services
  • Family Planning-Related Services
  • Billing Guidance
    • Billing on the CMS 1500 Claim Form
    • Billing on the UB-04 Claim Form
      • Female Sterilization
      • Male Sterilization
• Abortion Services
  • Abortions
    • Eligibility Categories
  • Covered Services
  • Family Planning Expanded Income Population (FAMPL) and Abortion Access
  • Treatment for Non-Viable Pregnancy
  • Claim Submission Requirements
    • Separation of State-Funded and Federally Matched Services
  • Modifier and Telemedicine Guidance
    • Family Planning Modifiers: FP and FP+32
    • Telemedicine and S0199
  • Procedure Codes
    • Abortion and Pregnancy-Related Procedure Codes
    • Surgical Procedure Codes
• Women’s Health Care
  • Women’s Health Services
  • Hysterectomies
• CMS 1500 Reference Table
  • Reproductive Health Care Claim Example
• Hospital Inpatient Billing
• Billing Information
• Timely Filing
• Reproductive Health Care Billing Manual Revisions Log

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Family Planning and Family Planning-Related Services

Covered Services

Family planning services mean those services provided to members of child-bearing age, including sexually active minors, with the intent to delay, prevent, or plan for a pregnancy. 
Family planning services may include: physical examinations, diagnoses, treatments, counseling, supplies (including all FDA-approved contraceptives, except spermicides and female condoms), Prescriptions, follow-up visits to evaluate or manage outcomes associated with contraceptive methods, pregnancy tests, sterilization services, and counseling services focused on preventing, delaying, or planning a pregnancy.

Non-Covered Family Planning Services

Services to identify and/or treat a member’s infertility concerns are not included as a Family Planning-related service, nor is infertility a covered Health First Colorado Service.

Voluntary Sterilization 

Sterilization for family planning is a covered benefit. 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 procedure codes:

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Requirements for Sterilization Procedures

Claims for sterilization procedures should be submitted electronically. A copy of the Health First Colorado Consent for Sterilization- MED 178 Form, located on the Provider Forms Web Page under the Sterilization Consent Forms drop-down menu. If more than one provider bills for a sterilization procedure, each provider must include a copy of the consent form with their own claim. This includes the hospital, surgeon, the anesthesiologist, and the assistant surgeon. Even though it is one procedure and one consent form, the form must be sent with every related claim or that claim may be denied.

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Informed Sterilization 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 performance 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
  • Advise 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
    • 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 ensure that the provisions of the law have been followed before Health First Colorado payment can be made for sterilization procedures. Information entered on the consent form must correspond directly to the information on the submitted Health First Colorado claim form. 

A copy of the Consent to Sterilization - MED 178 Form must be attached to every claim submitted for reimbursement of sterilization charges. If more than one provider bills for a sterilization procedure, each provider must include a copy of the consent form with their own claim. This includes the hospital, surgeon, the anesthesiologist, and the assistant surgeon. Even though it is one procedure and one consent form, the form must be sent with every related claim or that claim may be denied. 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. 

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.

Exceptions

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 they gave informed consent for the sterilization.
• Premature Delivery
  A member may consent to sterilization at the time of the premature delivery if at least 72 hours have passed since they gave informed consent for the sterilization, and the consent was obtained at least 30 days before the expected date of delivery. 
  The person may not be an "institutionalized individual."
  Institutionalized includes:
  • Involuntary 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 claims resulting from providers' 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 (§§ 25.5-4-300.4 — 25.5-4-310).

The following procedure codes are examples used for sterilization:

• 58600
• 58605
• 58565
• 58670
• 55450
• 55250
• 58611

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 in the Billing Guidance section. 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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Basic Fertility Services

• Counseling services focused on understanding the basic reproductive health system and fertility cycle, as related to methods to prevent, delay or plan for a pregnancy
• Basic fertility evaluations may include a pelvic exam, ultrasounds, or sperm analysis to support a member’s understanding of their ability to achieve a healthy pregnancy. 

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Family Planning-Related Services

Family planning-related services are essential, medically necessary services provided in a family planning setting as part of or as follow-up to a family planning visit. Such services are provided because they were identified or diagnosed during a family planning visit.

Family planning-related services could include:

• Drugs for the treatment of Sexually Transmitted Diseases (STD) or Sexually Transmitted Infections (STI) when the STD/STI is identified, or diagnosed, during a routine or periodic family planning visit. A follow-up encounter for STD/STI treatment and drugs may be covered. In addition, subsequent follow-up visits to rescreen for STIs/STDs based on the Centers for Disease Control and Prevention guidelines may be covered.
• A comprehensive patient history, physical, laboratory tests, contraceptive counseling, cervical cancer screening, and other prevention services, regardless of gender.
• Drugs for the treatment of lower genital tract and genital skin infections/disorders, and urinary tract infections, when the infection or disorder is identified or diagnosed, during a routine or periodic family planning visit. A follow-up encounter for treatment or drugs may be covered.
• Reproductive health-related evaluations or preventive services (related to reproductive health and identified on the U.S. Preventive Service Task Force, A & B Recommendations) such as cervical cancer screening, syphilis, chlamydia and gonorrhea screening, HIV screening, tobacco cessation services, or depression screening. 
   

Licensed practitioners must be enrolled with Health First Colorado. They must only render family planning-related services within the scope of their practice. Claims should have the appropriate CPT/HCPCS codes that are designated as family planning services with the FP+32 modifiers (excluding any abortion services) at the detail level on the claim. 

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Billing Guidance

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

The ICD-10 Sterilization Diagnosis Code:  Z30.2 (Encounter for sterilization) and appropriate procedure code (with the FP modifier) OR 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:

ICD-10 PCS Female Sterilization

Legend:

Section: 0=Medical and Surgical 

Body System: U= Female Reproductive System 

Body Part:

• 2 = Ovaries, Bilateral
• 7 = Fallopian Tubes, Bilateral

Approach: 

• 0 = Open
• 3 = Percutaneous
• 4 = Percutaneous Endoscopic
• 7 = Via Natural or Artificial Opening
• 8 = Via Natural or Artificial Opening Endoscopic
• F = External

Device:

• C, D, Z (most sterilization is Z= no device)

Qualifier:

• Z = no qualifier
• X = Diagnostic (for excision/biopsy)

Destruction (Root Operation =5)

All destruction codes: device = Z, qualifier = Z

Division (Root Operation = 8)

Pattern: 0 U 8 2 (Approach 0, 3, 4) ZZ

(Only ovaries, Bilateral)

Device= Z, Qualifier = Z

Excision (Root Operation = B)

Pattern: 0 U B [Body Part 2 or 7] [Approach 0,3,4,7,8] Z [Qualifier X or Z]

Excision – Ovaries, Bilateral (Body Part = 2)

Excision – Fallopian Tubes, Bilateral (Body Part = 7)

Device= Z for all excision codes

Occlusion (Root Operation = L)

4A. Occlusion – Fallopian Tubes, Bilateral, Approaches 0/3/4

Pattern: 0 U L 7 [Approach 0,3,4] [Device C,D,Z] Z

Occlusion- Fallopian Tubes, Bilateral, Approaches 7/8

Pattern: 0 U L 7 [Approach 7,8] [Device D,Z] Z

Resection (Root Operation = T)

Pattern: 0 U T [Body Part 2 or 7] [Approach 0,4,7,8,F] Z Z

Resection – Ovaries, Bilateral (Body Part = 2)

Resection- Fallopian Tubes, Bilateral (Body Part = 7)

Device= Z, Qualifier= Z for all resection codes

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ICD-10 PCS Male Sterilization (Bilateral)

Legend:

Section: 0 = Medical and Surgical

• Body System: V = Male Reproductive System
• Body Part: Q = Vas Deferens, Bilateral
• Root Operations:
  • 5 = Destruction
  • B = Excision
  • L = Occlusion
  • T = Resection
• Approaches: 0 (Open), 3 (Percutaneous), 4 (Percutaneous Endoscopic), 8 (Via natural or artificial opening endoscopic)
• Device: C, D, Z (depending on operation)
• Qualifier: Z (or X for excision-diagnostic)

Destruction of Vas Deferens, Bilateral (Root Operation = 5)

Pattern: 0 V 5 Q [Approach 0,3,4,8] Z Z

Meaning: Destroying both vas deferens (e.g., burning, cutting with destruction intent).

Excision of the Vas Deferens, Bilateral

Root Operation = B
Pattern: 0 V B Q [Approach: 0,3,4,8] Z [Qualifier X or Z]

Excision – Therapeutic/Non-Diagnostic (Qualifier = Z)

Excision- Diagnostic (Qualifier = X)

Occlusion of the Vas Deferens, Bilateral 

Root Operation = L

Pattern: 0 V L Q [Approach: 0,3,4,8] [Device: C, D, Z] Z

Open Approach (0) 

Percutaneous Approach (3)

Percutaneous Endoscopic Approach (4)

Via Natural or Artificial Opening Endoscopic (8) 

Resection of Vas Deferens, Bilateral

Root Operation = T 

Pattern: 0 V T Q [Approach: 0,4] Z Z 

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Abortion Services

Abortions

Effective January 1, 2026, coverage of abortion services was expanded in compliance with SB25-183 for the following eligibility categories:

Eligibility Categories 

• Medicaid (TXIX), including Cover all Coloradoans
• Emergency Medicaid Services, also referred to as “Emergency Medical (EMS) and Reproductive Health Care Program (RHCS)”. Please see Health First Colorado’s Emergency Services Program web page for more information on the emergency services covered under the EMS benefit plan.
• Child Health Plan Plus (CHP+)

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Covered Services

Services related to abortions will be fully covered via state funds for members enrolled in the above programs, regardless of circumstance. Members will no longer be subject to member deductibles, co-payments, or co-insurance for these services and may not be billed for them ( CO Rev. Stat. §25.5-4-301).

CHP+ providers must submit their claims to their CHP+ Managed Care Organization (MCO) for manual reconciliation reimbursement. 

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Family Planning Expanded Income Population (FAMPL) and Abortion Access 

The FAMPL population receives federal match, under Senate Bill 21-025, an “eligible member” for FAMPL is defined as one who:

• Is not pregnant and whose income does not exceed the state’s current effective income level for pregnant people under the Children’s Health Plan Plus (CHP+).
• Refer to the Family Planning Expansion Billing Manual for more information on the expansion eligibility groups.

Considering federal matching may not be used for abortion procedures, FAMPL members cannot receive abortion coverage while remaining in the federally matched eligibility category.

The following guidance outlines how FAMPL members can access abortion care.

• The member must report the pregnancy
• The member will then be automatically moved into CHP+, which covers abortion services billed with Z33.2 using state-only funds.
• The member will receive 12 months of continuous CHP+ coverage, during which abortion services are payable.

Providers should assist members, when appropriate, in understanding the need to report pregnancy to ensure correct benefit enrollment for the services they are seeking.

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Treatment for Non-Viable Pregnancy

The Department will continue to seek federal match regarding treatment related to non-viable pregnancies. No documentation is required for reimbursement of non-viable pregnancy treatment. When a member receives treatment for a non-viable pregnancy condition, an appropriate diagnosis code (listed below) must be listed:

• O00.0-O00.9 Ectopic Pregnancy
• O01.0-O01.9 Hydatidiform mole
• O02.0-O02.9 Other abnormal products of conception
• O02.1 Missed Abortion (incomplete miscarriage)
• O03.0-O03.9 Spontaneous Abortion
• O08.0-O08.9 Complications following ectopic and molar pregnancy

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Claim Submission Requirements

Separation of State-Funded and Federally Matched Services (Professional Claims Only)

All abortion and abortion related-services must be billed together on a single claim funded by state-only dollars. Other services provided on the same date of service that qualify for a federal match must be billed on a separate claim:

Example:

• A member receives an abortion and an Intrauterine Device (IUD) insertion on the same date of service:
  • Claim 1 (state-funded):
    • Abortion procedure and all abortion-related services
    • No FP or FP+32 modifiers
  • Claim 2 (federally matched):
    • IUD device and insertion
    • FP or FP+32 modifiers, as appropriate

This ensures accurate federal vs. state fund allocation and prevents claim denials, reprocessing, or potential recoupment.

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Modifier and Telemedicine Guidance

Family Planning Modifiers: FP and FP+32

Although abortion is classified as a family planning service under state law, abortion claims must not include the FP or FP+32 modifiers. FP modifiers indicate federally matched services, and abortion services are reimbursed with state-only funds. Using the FP modifiers on abortion claims will cause claims reprocessing or denials.

The Department requests that providers not append FP to FP+32 modifiers to abortion procedures, abortion-related E/M services, telemedicine components of abortion care, and S0199 abortion service bundles.

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Telemedicine and S0199

Effective January 1, 2026, providers are no longer required to append Modifier 52 to S0199 when telemedicine is used for any portion of the service. Telemedicine may be used for components such as counseling, follow-up consultation, or confirmation of pregnancy.

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Procedure Codes

Elective abortions are identified via diagnosis code Z33.2; no documentation is required for reimbursement of elective abortion-related services. Current system restrictions limiting abortion coverage to cases of incest, rape, or life endangerment will be removed, effective January 1, 2026.

Abortion and Pregnancy-Related Procedure Codes

The following CPT codes are appropriate for abortion and pregnancy-related services:

• 01964
• 01965
• 01966
• 58120
• 59100
• 59812-59830
• 59840
• 59841
• 59850
• 59851
• 59852
• 59855
• 59856
• 59857
• S0190
• S0191
• S0199

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Surgical Procedure Codes

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

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Women’s Health Care

Women’s Health Services

Women’s Health Services include annual primary care, gynecological care, and other targeted reproductive tissue-related health care services such as:

• Sexually Transmitted Infection (STI) testing and treatment
• Hysterectomies
• Mastectomies, when medically necessary
• Breast reconstruction (Following and within 5 years of a mastectomy)
• Other reproductive tissue removal, when medically necessary

Women’s Health Services also include related preventive services as identified by the U.S. Preventive Services Task Force (USPSTF) and Health Resources and Services Administration (HRSA) recommendations. 

Preventive services may include:

• Cervical Cancer Screening
• Mammograms
• BRCA genetic screening, when medically necessary, with genetic counseling and testing
• HPV vaccinations
• Any other relevant preventive services, as identified by the USPSTF

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Hysterectomies

Hysterectomy is a benefit of Health First Colorado when performed solely for medical reasons. 

Hysterectomies require an appropriately signed Departmental Acknowledgement/ Certification Statement form as a claim attachment for reimbursement for services rendered.

Hysterectomies are not considered a family planning benefit nor a Health First Colorado benefit if:

• The hysterectomy is performed solely for sterilization, or
• If there was more than one purpose for the procedure, and it would not have been performed but for sterilization.

The following conditions must be met for hysterectomy claims reimbursement:

• The claims must be submitted electronically
• Prior to the surgery, the person who secures 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 (sterile).
• The member and the person's representative, if any, must sign a Departmental Acknowledgement/Certification Statement Form for Hysterectomy 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 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
• The member required the hysterectomy under a life-threatening emergency in which the practitioner determined that prior acknowledgment by the member was not possible. The statement form 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 Form for a Hysterectomy, 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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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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Reproductive Health Care Claim Example

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Hospital Inpatient Billing

For hospital inpatient billing, the FP and FP+32 modifiers cannot be added to the detail level of the claim. For inpatient services, such as sterilization or Immediate Postpartum Long-Acting Reversible Contraception (IPP-LARC) device insertion, providers must use the ICD-10 diagnosis and surgical procedural (PSC) codes below to identify the family planning service.

Refer to the IPP-LARC section of the Inpatient/Outpatient Billing Manual for further IPP-LARC billing instructions.

Refer to the Immediate Post-Partum Long-Acting Reversible Contraceptives (IPP-LARCs) information under the Separate Procedures section of the Obstetrical Care Billing Manual.

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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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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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Reproductive Health Billing Manual Revision Log