CO · guidance

CO HCPF Reproductive Health Care Billing Manual — Abortion Services

AbortionServices

activein force · 2026-07-26 – presentas-observed

EffectiveJanuary1,2026,coverageofabortionserviceswasexpandedincompliancewithSB25-183forthefollowingeligibilitycategories:

Medicaid(TXIX),includingCoverallColoradoans

EmergencyMedicaidServices,alsoreferredtoas“EmergencyMedical(EMS)andReproductiveHealthCareProgram(RHCS)”.PleaseseeHealthFirstColorado’sEmergencyServicesProgramwebpageformoreinformationontheemergencyservicescoveredundertheEMSbenefitplan.

ChildHealthPlanPlus(CHP+)

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Servicesrelatedtoabortionswillbefullycoveredviastatefundsformembersenrolledintheaboveprograms,regardlessofcircumstance.Memberswillnolongerbesubjecttomemberdeductibles,co-payments,orco-insurancefortheseservicesandmaynotbebilledforthem(CORev.Stat.§25.5-4-301).

CHP+providersmustsubmittheirclaimstotheirCHP+ManagedCareOrganization(MCO)formanualreconciliationreimbursement.

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TheFAMPLpopulationreceivesfederalmatch,underSenateBill21-025,an“eligiblemember”forFAMPLisdefinedasonewho:

Isnotpregnantandwhoseincomedoesnotexceedthestate’scurrenteffectiveincomelevelforpregnantpeopleundertheChildren’sHealthPlanPlus(CHP+).

RefertotheFamilyPlanningExpansionBillingManualformoreinformationontheexpansioneligibilitygroups.

Onceamemberbecomespregnant,theyarenolongereligiblefortheFAMPLprogram.

ThestepsbelowdescribetheprocessforFAMPLmemberstoobtaincoveredabortionservices:Themembermustreportthepregnancy

Thememberwillthenbeevaluatedforanothereligibilitybenefitcategory,whichcoverselectiveabortionsbilledwithZ33.2usingstate-onlyfunds

Thememberwillreceive12monthsofcoveragebeginningattheendofthepregnancy.Providersshouldassistmembers,whenappropriate,inunderstandingtheneedtoreportpregnancytoensurecorrectbenefitenrollmentfortheservicestheyareseeking

Contacthcpf_maternalchildhealth@state.co.uswithpolicyquestionsregardingtheFAMPLprogram

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TheDepartmentwillcontinuetoseekfederalmatchregardingtreatmentrelatedtonon-viablepregnancies.Nodocumentationisrequiredforreimbursementofnon-viablepregnancytreatment.Whenamemberreceivestreatmentforanon-viablepregnancycondition,anappropriatediagnosiscode(listedbelow)mustbelisted:

O00.0-O00.9EctopicPregnancy

O01.0-O01.9Hydatidiformmole

O02.0-O02.9Otherabnormalproductsofconception

O02.1MissedAbortion(incompletemiscarriage)

O03.0-O03.9SpontaneousAbortion

O08.0-O08.9Complicationsfollowingectopicandmolarpregnancy

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Allabortionandabortionrelated-servicesmustbebilledtogetheronasingleclaimfundedbystate-onlydollars.Otherservicesprovidedonthesamedateofservicethatqualifyforafederalmatchmustbebilledonaseparateclaim:

Example:

Abortionprocedureandallabortion-relatedservices

NoFPorFP+32modifiers

IUDdeviceandinsertion

FPorFP+32modifiers,asappropriate

Thisensuresaccuratefederalvs.statefundallocationandpreventsclaimdenials,reprocessing,orpotentialrecoupment.

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HealthFirstColoradocoversmedicationabortions,typicallybilledwithHCPCScodesS0190/S0191/S0199.Providersmustsubmitcompleteandaccurateinformationwhenbillingforabortionmedications,includingthedruginvoice.

WhyAdditionalDocumentationisRequired

MifepristoneandMisoprostolaretreatedasphysician-administereddrugs(PAD)underHealthFirstColoradopolicy.PADsarereimbursedbasedontheamountofdrugadministeredandacquiredbytheproviderviastandardbuy-and-billprocesses,notaflatorbundledrate.

ThisrequirementappliestoallprovidersbillingforPADsandisnotuniquetoabortionservices.RatesforPADsareupdatedonaquarterlybasisandpublishedonthePADFeeSchedule.PADslistedasmanuallypriced(MP)onthePADFeeSchedulerequirethedruginvoicetobeattachedtotheclaim.MPPADsarereviewedandpricedbythefiscalagent.

WhatMustBeSubmittedwiththeClaim

WhenbillingS0190and/orS0191,providersmustensurethefollowinginformationisavailableandsubmittedasrequired:

Reportthe11-digitNDCfortheactualdrugadministered.

TheNDCmustcorrespondtothemifepristoneormisoprostolproductuse.

AppendixXprovidesadditionalguidanceregardingreimbursableHCPCS/NDCcombinations.ClaimssubmittedwithoutavalidormatchingNDCmaybedenied.

Acopyofthedrugpurchaseinvoicemustbeavailableandsubmittedforphysician-administereddrugsthataremanuallypriced(S0190andS0191).

Drugname

NDC

Quantitypurchased

Costpaidbytheprovider

Thisdocumentationisusedtovalidatereimbursementandisrequiredforphysician-administereddrugclaims.

Medicationabortiondrugclaimsmaybesubjecttopost-paymentreview;failuretoproviderequireddocumentationwhenrequestedmayresultinclaimdenialorrecoupment.Theserequirementsarepartoftheexistingphysician-administereddrugbillingpolicyandapplyregardlessofprovidertypeorsetting.

MoreextensivePADbillingguidancemaybefoundinthePhysicianAdministeredDrugbillingmanual,andquestionscanbedirectedtohcpf_pad@state.co.us.

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Althoughabortionisclassifiedasafamilyplanningserviceunderstatelaw,abortionclaimsmustnotincludetheFPorFP+32modifiers.FPmodifiersindicatefederallymatchedservices,andabortionservicesarereimbursedwithstate-onlyfunds.UsingtheFPmodifiersonabortionclaimswillcauseclaimsreprocessingordenials.

TheDepartmentrequeststhatprovidersnotappendFPtoFP+32modifierstoabortionprocedures,abortion-relatedE/Mservices,telemedicinecomponentsofabortioncare,andS0199abortionservicebundles.

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EffectiveJanuary1,2026,providersarenolongerrequiredtoappendModifier52toS0199whentelemedicineisusedforanyportionoftheservice.Telemedicinemaybeusedforcomponentssuchascounseling,follow-upconsultation,orconfirmationofpregnancy.

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ElectiveabortionsareidentifiedviadiagnosiscodeZ33.2;nodocumentationisrequiredforreimbursementofelectiveabortion-relatedservices.Currentsystemrestrictionslimitingabortioncoveragetocasesofincest,rape,orlifeendangermentwillberemoved,effectiveJanuary1,2026.

ThefollowingCPTcodesareappropriateforabortionandpregnancy-relatedservices:

01964

01965

01966

58120

59100

59812-59830

59840

59841

59850

59851

59852

59855

59856

59857

S0190

S0191

S0199

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10A00ZZ

10A07Z6

10A07ZW

10A07ZX

10A07ZZ

10A08ZZ

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: a09397375d83f981dd70fa1509deae4f86b99dd22c747abbc076ded8eb31dbb7

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