PHE Telehealth Policy Clarification for Medication Abortion: HCPCS Code S0199
Originally published July 13, 2022
Updated January 9, 2023
On January 9, 2023, Medi-Cal announced that DHCS will allow a timeliness waiver for claims with dates of service on or after March 1, 2020, as a result of policy clarification for HCPCS code S0199. The timeliness waiver will remain in effect until August 31, 2023.
The Department of Health Care Services (DHCS) is issuing clarification of requirements for HCPCS code S0199 (medically induced abortion by oral ingestion of medication including all associated services and supplies [e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion] except drugs), effective during the COVID-19 Public Health Emergency (PHE). As specified in DHCS's telehealth guidance, services may be provided via telehealth when:
- The treating health care practitioner at the distant site believes that the Medi-Cal benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth, subject to oral or written consent by the beneficiary.
- The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual.
- The benefits or services provided via telehealth satisfies all laws regarding confidentiality of health care information and a patient’s right to their medical information.
For services billed under HCPCS code S0199 for dates on or after March 1, 2020, and through the last day of the COVID-19 PHE:
- When determined clinically appropriate based on a provider’s clinical judgement, services may be provided through telehealth. Confirmation of pregnancy must be documented.
- Ultrasound to confirm gestational age and/or intrauterine pregnancy, and ultrasound to confirm completion of abortion, must be provided when clinically indicated but is not required in all cases.
- For recipients for whom a follow-up visit or abortion completion assessment is not conducted (either in person, via telehealth, or via electronic communication), modifier 52 (reduced services) must be billed with code S0199 using the “from-through” method with the “no show” date as the “through” date.
- If all clinically indicated services and supplies associated with medically induced abortion by oral ingestion of medication, excluding drugs, are provided, including a follow-up visit or an abortion completion assessment as described in the above bullet, HCPCS code S0199 may be billed without the use of modifier 52.
- S0199 may be billed without the use of modifier 52 when one or more ultrasounds are not provided, when one or more ultrasounds is determined clinically unnecessary based on a provider’s clinical judgement.
As specified in the above telehealth guidance, delivery of benefits or services that require the in-person presence of the patient for any reason are not appropriate for delivery via a telehealth modality.