SUBJECT: Update to Abortion Condition Codes Associated With Reason Code 32809

Transcription

1 anual ystem Pub edicare laims Processing Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 2397 Date: January 26, 2012 hange equest 7687 UBJT: Update to bortion ondition odes ssociated With eason ode UY O NG: This hange equest will be used to update reason code with the correct condition codes as follows: ondition ode Performed due to ape BPerformed due to ncest DPerformed due to life endangering physical condition Previous condition codes 7 and 8 have been discontinued and reserved for national assignment effective October 1, TV DT: October 1, 2002 PLNTTON DT: July 2, 2012 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTUTON: (N/ if manual is not updated) =VD, N=NW, D=DLTD-Only One Per ow. /N/D PT / TON / UBTON / TTL 3/100.1/Billing for bortion ervices. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets. or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

2 V. TTNT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

3 ttachment - Business equirements Pub Transmittal: 2397 Date: January 26, 2012 hange equest: 7687 UBJT: Update to bortion ondition odes ssociated With eason ode TV DT: October 1, 2002 PLNTTON DT: July 2, GNL NOTON. Background: ffective October 1, 1998, abortions are not covered under the edicare program except for instances where the pregnancy is a result of an act of rape or incest; or the woman suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused by the pregnancy itself that would (as certified by a physician) place the woman in danger of death unless an abortion is performed. Beginning July 1, 1999, providers billed for abortion services using odifier G7 defined as "the pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening." This modifier is used on claims with dates of services October 1, 1998 to the present. B. Policy: This hange equest will be used to update reason code with the correct condition codes as follows: ondition ode B D Description bortion Performed due to ape bortion Performed due to ncest bortion Performed due to life endangering physical condition Previous condition codes 7 and 8 have been discontinued and reserved for national assignment effective October 1, BUN QUNT TBL Use hall" to denote a mandatory requirement Number equirement esponsibility (place an X in each applicable column) / D hared- ystem B aintainers shall update reason code with the current condition codes as follows: bortion Performed due to ape B bortion Performed due to ncest X V W O T

4 Number equirement esponsibility (place an X in each applicable column) / D hared- ystem B aintainers D bortion Performed due to life endangering physical condition shall update other edits pertaining to this policy. X edicare contractors shall reprocess claims brought to their attention X X V W O T. POVD DUTON TBL Number equirement esponsibility (place an X in each applicable column) / D hared- ystem B aintainers provider education article related to this instruction will be available at shortly after the is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in your next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. X X V W O T V. UPPOTNG NOTON ection : or any recommendations and supporting information associated with listed requirements, use the box below: N/ Use "hould" to denote a recommendation.

5 X-ef equirement Number ecommendations or other supporting information: ection B: or all other recommendations and supporting information, use this space: N/ V. ONTT Pre-mplementation ontact(s): hauntari heely, arah hirey-losso, Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), egional ome ealth ntermediaries (s), and/or arriers, use only one of the following statements: No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

6 edicare laims Processing anual hapter 3 - npatient ospital Billing Billing for bortion ervices (ev.2397, ssued: , ffective: , mplementation: ) ffective October 1, 1998, abortions are not covered under the edicare program except for instances where the pregnancy is a result of an act of rape or incest; or the woman suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused by the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.. "G" odifier The "G7" modifier is defined as "the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening." Beginning July 1, 1999, providers should bill for abortion services using the new odifier G7. This modifier can be used on claims with dates of services October 1, 1998, and after. W will be able to recognize the modifier beginning July 1, B. Billing nstructions 1. ospital npatient Billing ospitals will bill the on orm using bill type 11X. edicare will pay only when condition codes: B D bortion Performed due to ape bortion Performed due to ncest bortion Performed due to life endangering physical condition in Ls of UB04 along with an appropriate D-9- principal diagnosis code that will group to DG 770 (bortion W D&, spiration urettage Or ysterotomy) or with an appropriate D-9- principal diagnosis code and one of the four appropriate D-9-/ D-10- operating room procedure codes listed below that will group to DG 779 (bortion W/O D&). D-9- D ZZ bortion of Products of onception, Via Natural or rtificial Opening 1008ZZ bortion of Products of onception, Via Natural or rtificial Opening ndoscopic D17ZZ xtraction of Products of onception, etained, Via Natural or

7 rtificial Opening 10D18ZZ xtraction of Products of onception, etained, Via Natural or rtificial Opening ndoscopic ZZ bortion of Products of onception, Via Natural or rtificial Opening 1008ZZ bortion of Products of onception, Via Natural or rtificial Opening ndoscopic ZZ bortion of Products of onception, Open pproach 1003ZZ bortion of Products of onception, Percutaneous pproach 1004ZZ bortion of Products of onception, Percutaneous ndoscopic pproach Providers must use D-9- codes and or the related 1D-10- codes to describe exactly the procedure or service performed. The must manually review claims with the above D-9-/D-10- procedure codes to verify that all of the above conditions are met. 2. Outpatient Billing ospitals will bill the on orm using bill type 13X, 83X and 85X. edicare will pay only if one of the following PT codes is used with the "G7" modifier ommon Working ile (W) dits or hospital outpatient claims, W will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with the "G7" modifier and one of the above PT codes. or hospital inpatient claims, W will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with one of the above D-9- procedure codes. D. edicare ummary Notices (N)/xplanation of Your edicare Benefits emittance dvice essage f a claim is submitted with one of the above PT procedure codes but no "G7" modifier, the claim is denied. The states on the N the following message: This service was denied because edicare covers this service only under certain circumstances." (N essage 21.21).

8 or the remittance advice the uses existing merican National tandard nstitute (N) X claim adjustment reason code B5, "laim/service denied/reduced because coverage guidelines were not met or were exceeded."