Provider Notice issued 12/15/05

Billing Requirements for Mifepristone

The purpose of this notice is to clarify the billing instructions for the three office visits required to complete the termination of a pregnancy by the use of Mifepristone.

Billing Requirements

Providers must bill procedure code H0033 along with the appropriate “U” modifier to identify termination of pregnancy by use of Mifepristone. The following are the “U” modifiers:

U4 – Pregnancy resulting from rape
U7 – Pregnancy resulting from incest
U8 – Pregnancy is threatening the mother’s life
U9 – Pregnancy endangers the mother’s health

The department will reimburse the physician a global rate of $118.10 for the three visits required to complete the procedure. The three visits consist of the initial visit, the two-day follow-up and two-week follow-up required under the FDA protocol. Providers must bill a quantity of “1” with procedure code H0033 to designate the three-visit package.

Procedure code H0033 may only be billed once per pregnancy. The physician does not have to wait until after the third visit to bill the department. The H0033 procedure may be billed to the department after the first visit. In the event that the patient does not return for the follow-up visits and seeks treatment from another physician, the department will not require a refund of the global payment made after the first office visit. In this situation, the physician providing the follow-up services should use the appropriate CPT code to bill for the visit.

Providers must continue to bill the individual drugs used in this process, Mifepristone and Misoprostol, under their respective HCPCS codes and NDCs. An HFS 2390, Abortion Payment Application, must be completed and submitted along with the claim.

Policy

The use of Mifepristone, in conjunction with Misoprostol, as a method to terminate a pregnancy is only a covered service when the reason for performing the procedure complies with department policy and it is administered in accordance with the FDA protocol. The department’s policy states termination of a pregnancy is only covered when, in the professional judgment of a physician licensed to practice medicine in all of its branches, the life of the patient would be endangered if the fetus were carried to term, or the pregnancy is the result of rape or incest, or the procedure is performed to protect the patient’s health.

Providers wishing to receive e-mail notification, when new provider information is posted by the department, may register at the following HFS Web site at:

http://www.illinois.gov/hfs/MedicalProviders/notices/Pages/default.aspx

If you have questions regarding this notice, please contact the Bureau of Comprehensive Health Services at 1-877-782-5565.

Anne Marie Murphy, Ph.D.
Administrator
Division of Medical Programs