59855
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
6.27
Facility
$385.78
Non-Facility
$385.78
Documentation Required
- Appropriate ICD-10 diagnosis codes to support elective (e.g., Z33.2, Z32.01) or therapeutic abortion (specific maternal or fetal condition codes) must be submitted with claims.
- Documentation of the underlying maternal health condition or fetal disease when therapeutic abortion CPT/HCPCS codes are used (e.g., clinical notes, diagnoses such as cancer, cardiac disease, fetal genetic abnormality, evidence of fetal demise, rape/incest documentation where applicable).
- For medication-induced abortion, documentation of associated services is expected per S0199 description: patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, and ultrasound to confirm completion of abortion.
- Clinical records to document complications and medically necessary treatment when treating spontaneous abortion (missed, incomplete, infected/septic abortion) or post-abortion complications.
Key Coverage Criteria
- Elective abortion: termination of pregnancy at the discretion of the woman for reasons other than maternal health or fetal disease. Elective abortion is reflected when ICD-10-CM code Z33.2 (Encounter for elective termination of pregnancy) is billed alone or with Z32.01 (Encounter for pregnancy test, result positive).
- Therapeutic abortion: termination of pregnancy due to underlying conditions related to maternal health or fetal disease. Indications include (but are not limited to) cancer; cardiovascular, hematologic or pulmonary disease; congenital heart disease; diabetes mellitus; ectopic pregnancy; exposure to a teratogenic substance known to cause fetal malformation(s); fetal genetic abnormalities; fetal death prior to the age of viability; fetal structural defects (e.g., neural tube defects, cardiac abnor [...]
- Medically necessary treatment of complications following an abortion (e.g., missed or incomplete abortion, infected/septic abortion) is covered.
- Ectopic pregnancy (implanted outside the uterus) is covered and may require immediate surgical intervention as it constitutes a life-threatening condition.
- Therapeutic abortion for treatment of a life‑threatening condition related to maternal health may be billed using the following CPT codes (may be used in combination with any diagnosis code[s]): 59100, 59120, 59121, 59130, 59136, 59140, 59150, 59151, 59812, 59820, 59821, 59830, 59870.
- Induced abortion procedures that reflect therapeutic abortion when accompanied by diagnosis codes indicating underlying maternal/fetal conditions include CPT codes: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866.
2 Active Policies
CIGNA-A006 — Abortion - (A006)
HUMANA-ABORTION-HYSTERECTOMY-AND-STERILIZATION-LA-MEDICAID — Abortion, Hysterectomy and Sterilization - MEDICAID - LOUISIANA
Related Codes
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