Covered and Noncovered Services : Surgery Services

Abortions

Coverage Policy

In accordance with Wis. Stat. § 20.927, abortions are covered when one of the following situations exists:

• The abortion is directly and medically necessary to save the life of the woman, provided that prior to the abortion the physician attests, based on their best clinical judgment, that the abortion meets this condition by signing a certification.
• In a case of sexual assault or incest, provided that prior to the abortion the physician attests that sexual assault or incest has occurred, to their belief, by signing a written certification; the crime must also be reported to the law enforcement authorities.
• Due to a medical condition existing prior to the abortion, provided that prior to the abortion the physician attests, based on their best clinical judgment, that the abortion meets the following condition by signing a certification that the abortion is directly and medically necessary to prevent grave, long-lasting physical health damage to the woman.

When submitting a claim to ForwardHealth, physicians are required to attach or upload via the ForwardHealth Portal a completed and signed certification statement attesting to one of the previous circumstances. The optional Abortion Certification Statements form is available to use in this situation. Providers may develop a form of their own, as long as it includes the same information.

Covered Services

When an abortion meets the state and federal requirements for Medicaid payment, office visits and all other medically necessary related services are covered. Treatment for complications arising from an abortion are covered, regardless of whether or not the abortion itself is a covered service, because the complications represent new conditions, and thus the services are not directly related to the performance of an abortion.

Coverage of Mifeprex

Wisconsin Medicaid reimburses for Mifeprex under the same coverage policy that it reimburses other surgical or medical abortion procedures under Wis. Stat. § 20.927.

When submitting claims for Mifeprex, providers are required to:

• Use the HCPCS code S0190 (Mifepristone, oral, 200 mg) for the first dose of Mifeprex, along with the E&M code that reflects the service provided. Do not use HCPCS code S0199; bill components (ultrasounds, office visits) of services performed separately.
• Use the HCPCS code S0191 (Misoprostol, oral, 200 mcg) for the drug given during the second visit, along with the E&M code that reflects the service provided. Do not use HCPCS code S0199; bill components (ultrasounds, office visits) of services performed separately.
• For the third visit, use the E&M code that reflects the service provided.
• Include the appropriate ICD abortion diagnosis code with each claim submission.
• Attach to each claim a completed abortion certification statement that includes information showing the situation is one in which the abortion is covered.

Note: ForwardHealth denies claims for Mifeprex reimbursement when billed with an NDC.

Physician Counseling Visits Under Wis. Stat. § 253.10

Wis. Stat. § 253.10, provides that a woman's consent to an abortion is not considered informed consent unless at least 24 hours prior to an abortion a physician has, in person, orally provided the woman with certain information specified in the statute.

Pursuant to this statute, Wisconsin DHS has issued preprinted material summarizing the statutory requirements and a patient consent form. Copies of these materials may be obtained by writing to the following address:

Administrator
Division of Public Health
PO Box 2659
Madison WI 53701-2659

An office visit during which a physician provides the information required by this statute is covered.

Services Incidental to a Noncovered Abortion

Services incidental to a noncovered abortion are not covered. Such services include, but are not limited to, any of the following services when directly related to the performance of a noncovered abortion:

• Anesthesia services
• Laboratory testing and interpretation
• Recovery room services
• Transportation
• Routine follow-up visits
• Ultrasound services