36.4.17.3 Elective AbortionsAccording to a revision of the Hyde Amendment, under P.L. 103-112, HHSC implemented the federal directive pertaining to Medicaid reimbursement for abortions. Federal funding is available to save the life of the mother and to terminate pregnancies resulting from rape or incest. Reimbursement is based on the physician's certification that the abortion was performed to save the mother's life, to terminate a pregnancy resulting from rape, or to terminate a pregnancy resulting from incest. Prior authorization for abortions is no longer required. In accordance with federal law, providers are required to use specific language regarding the reason the mother's condition is life-threatening. An abortion for a life-threatening condition must be due to a physical disorder, injury, or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself that would place the woman in danger of death unless an abortion was performed. Reimbursement of an abortion is based on the physician's certification that the abortion was performed to save the life of the mother, to terminate pregnancy resulting from rape, or to terminate pregnancy resulting from incest. One of the following statements signed by the physician is mandatory for any abortion performed. Substitute wording will not be accepted. One of these statements must accompany any claim for abortion to be considered for reimbursement:
•
•
• A stamped or typed physician signature is not acceptable on the original certification statement. The physician's signature must be an original signature. A copy of the signed certification statement must be submitted with each claim for reimbursement. Faxes and electronic billing are not acceptable or available at this time. The physician must maintain the original certification statement in the client's files. Abortion services must be billed with modifier W1 (endangerment of the mother's life), W2 (rape), or W3 (incest) to indicate the reason for the abortion. Performing physicians, facilities, anesthesiologists, and CRNAs must submit modifier G7 with the appropriate procedure code when requesting reimbursement for abortion procedures that are within the scope of the rules and regulations of the Texas Medicaid Program. Modifier G7 must be entered next to the procedure code that identifies the abortion services. Refer to: "Abortion Certification Statements Form" for a sample form. Drugs or devices to prevent implantation of the fertilized ovum and medical procedures necessary for the termination of an ectopic pregnancy are benefits of the Texas Medicaid Program. Important: To bill a Texas Medicaid client for a service that TMHP denies as not medically necessary, the billing provider must ensure that the client or client's guardian has signed an acknowledgment statement obtained by the physician who has contact with the client. |
"I, (physician's name), certify that on the basis of my professional judgment, an abortion procedure is necessary because (client's full name, Medicaid number, and complete address) suffers from a physical disorder, injury, or illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place her in danger of death unless an abortion is performed." (A signature is required.)
