Information is available for DOS between January 1, 2018, and October 1, 2018 (services for men).
Information is available for DOS between January 1, 2018, and October 1, 2018 (services for women).
Providers who submit claims for Family Planning Only Services using the UB-04 Claim Form and the 837I transactions are required to indicate a valid HCPCS procedure code for each revenue code on the claim. The HCPCS code should be entered in Form Locator 44 of the UB-04 Claim Form. This policy should be used in conjunction with service-specific claim submission policies.
ForwardHealth requires HCPCS procedure codes on claims to assist in monitoring reimbursement for covered services.
The following tables contain the procedure codes covered under Family Planning Only Services. In addition to indicating an appropriate covered procedure code, providers submitting claims for members enrolled in Family Planning Only Services are required to identify the service as family planning-related by associating the procedure with modifier FP (Service provided as part of family planning program) or the most appropriate ICD diagnosis code related to contraceptive management.
The following tables indicate which procedure code requires an allowable primary diagnosis code related to contraceptive management. "No" indicates that the allowable contraceptive management diagnosis code does not have to be in the primary position. If an ICD diagnosis code related to contraceptive management is not appropriate for the service provided, providers may instead use modifier FP associated with the procedure.
Claims for members enrolled in Family Planning Only Services that are submitted without either a modifier FP associated with the procedure code or an allowable primary ICD contraceptive management diagnosis code will be denied.
| Evaluation and Management Services | ||
|---|---|---|
| Procedure Code | Description | Requires Allowable Contraceptive Management Code as Primary Diagnosis Code |
| 99201 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making | Yes |
| 99202 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making | Yes |
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity | Yes |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity | Yes |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity | Yes |
| 99211 | Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional | Yes |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making | Yes |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity | Yes |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity | Yes |
| 99384 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) | Yes |
| 99385 | 18-39 years | Yes |
| 99386 | 40-64 years | Yes |
| 99394 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures established patient; adolescent (age 12 through 17 years) | Yes |
| 99395 | 18-39 years | Yes |
| 99396 | 40-64 years | Yes |
| 99401 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes | Yes |
| 99402 | approximately 30 minutes | Yes |
| 99403 | approximately 45 minutes | Yes |
| 99404 | approximately 60 minutes | Yes |
| Q3014 | Telehealth originating site facility fee | No |
| S9445 | Patient education, not otherwise classified, non-physician provider, individual, per session | Yes |
Note: S9445 not covered with procedure codes 99384-99396 and 99401-99404.
| Supplies and Drugs | ||
|---|---|---|
| Procedure Code | Description | Requires Allowable Contraceptive Management Code as Primary Diagnosis Code |
| A4261 | Cervical cap for contraceptive use | Yes |
| A4264 | Permanent implantable contraceptive intratubal occlusion device(s) and delivery system | Yes |
| A4266 | Diaphragm for contraceptive use | Yes |
| A4267 | Contraceptive supply, condom, male, each | Yes |
| A4268 | Contraceptive supply, condom, female, each | Yes |
| A4269 | Contraceptive supply, spermicide (e.g., foam, gel), each | Yes |
| G0101 | Cervical or vaginal cancer screening; pelvic and clinical breast examination | Yes |
| J0561 | Injection, penicillin G benzathine, 100,000 units | No |
| J0696 | Injection, ceftriaxone sodium [Rocephin], per 250 mg | No |
| J7296 | Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg | Yes |
| J7297 | Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52mg | Yes |
| J7298 | Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52mg | Yes |
| J7300 | Intrauterine copper contraceptive | Yes |
| J7303 | Contraceptive supply, hormone containing vaginal ring, each | Yes |
| J7304 | Contraceptive supply, hormone containing patch, each | Yes |
| J7307 | Etonogestrel (contraceptive) implant system, including implant and supplies | Yes |
| Q0144 | Azithromycin dihydrate, oral, capsules/powder, 1 gram | Yes |
| S4993 | Contraceptive pills for birth control | Yes |
| Anesthesia Services | ||
|---|---|---|
| Procedure Code | Description | Requires Allowable Contraceptive Management Code as Primary Diagnosis Code |
| 00851 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection | Yes |
| 00921 | Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral | No |
| 00952 | Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography | Yes |
| Surgery Services | ||
|---|---|---|
| Procedure Code | Description | Requires Allowable Contraceptive Management Code as Primary Diagnosis Code |
| 10060 | Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paraonychia); simple or single | Yes |
| 10140 | Incision and drainage of hematoma, seroma or fluid collection | Yes |
| 11420 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less | Yes |
| 11976 | Removal, implantable contraceptive capsules | Yes |
| 11981 | Insertion, non-biodegradable drug delivery implant | Yes |
| 11982 | Removal, non-biodegradable drug delivery implant | Yes |
| 11983 | Removal with reinsertion, non-biodegradable drug delivery implant | Yes |
| 17110 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions | No |
| 17111 | 15 or more lesions | No |
| 46900 | Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical | No |
| 46924 | Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) | No |
| 55250* | Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) | No |
| 56501 | Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) | No |
| 57061 | Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) | No |
| 57170 | Diaphragm or cervical cap fitting with instructions | Yes |
| 57452 | Colposcopy of the cervix including upper/adjacent vagina; | No |
| 57454 | with biopsy(s) of the cervix and endocervical curettage | No |
| 57455 | with biopsy(s) of the cervix | No |
| 57456 | with endocervical curettage | No |
| 57460 | with loop electrode biopsy(s) of the cervix | No |
| 57461 | with loop electrode conization of the cervix | No |
| 58300 | Insertion of intrauterine device (IUD) | Yes |
| 58301 | Removal of intrauterine device (IUD) | Yes |
| 58340 | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography | Yes |
| 58565* | Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants (The professional service only is reimbursed under CPT procedure code 58565. The implantable device is reimbursed under HCPCS procedure code A4264.) | Yes |
| 58600* | Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral | Yes |
| 58611* | Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) | Yes |
| 58615* | Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach | Yes |
| 58661 | Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salphingectomy) | Yes |
| 58670* | Laparoscopy, surgical; with fulguration of oviducts (with or without transection) | Yes |
| 58671* | with occlusion of oviducts by device (e.g. band, clip or Falope ring) | Yes |
| Radiology Services | ||
|---|---|---|
| Procedure Code | Description | Requires Allowable Contraceptive Management Code as Primary Diagnosis Code |
| 71045 | Radiological examination, chest; single view | Yes |
| 71046 | Radiological examination, chest; 2 views | Yes |
| 74740 | Hysterosalpingography, radiological supervision and interpretation | Yes |
| Medicine Services | ||
|---|---|---|
| Procedure Code | Description | Requires Allowable Contraceptive Management Code as Primary Diagnosis Code |
| 90649 | Human papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule, for intramuscular use | No |
| 90650 | Human papillomavirus vaccine, types 16, 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use | No |
| 90651 | Human papillomavirus vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use | No |
| 96372 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Yes |
| 99070 | Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) | Yes |
| Laboratory Services | ||
|---|---|---|
| Procedure Code | Description | Requires Allowable Contraceptive Management Code as Primary Diagnosis Code |
| G0123 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by cytotechnologist under physician supervision | Yes |
| 80048 | Basic metabolic panel (see CPT for tests that must be included in the panel) | Yes |
| 80050 | General health panel (see CPT for tests that must be included in the panel) | Yes |
| 80051 | Electrolyte panel (see CPT for tests that must be included in the panel) | Yes |
| 80061 | Lipid panel (see CPT for tests that must be included in the panel) | Yes |
| 80074 | Acute hepatitis panel (see CPT for tests that must be included in the panel) | Yes |
| 80076 | Hepatic function panel (see CPT for tests that must be included in the panel) | Yes |
| 81000 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy | Yes |
| 81002 | non-automated, without microscopy | Yes |
| 81025 | Urine pregnancy test, by visual color comparison methods | Yes |
| 82565 | Creatinine; blood [only used if patient is on medication for Herpes] | Yes |
| 82728 | Ferritin | Yes |
| 82746 | Folic acid; serum | Yes |
| 82947 | Glucose; quantitative, blood (except reagent strip) | Yes |
| 82948 | blood, reagent strip | Yes |
| 83001 | Gonadotropin; follicle stimulating hormone (FSH) | Yes |
| 83020 | Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) | Yes |
| 83518 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, single step method (eg, reagent strip) | Yes |
| 84146 | Prolactin | Yes |
| 84443 | Thyroid stimulating hormone (TSH) | Yes |
| 84450 | Transferase; aspartate amino (AST) (SGOT) | Yes |
| 84702 | Gonadotropin, chorionic (hCG); quantitative | Yes |
| 84703 | qualitative | Yes |
| 85007 | Blood count; blood smear, microscopic examination with manual differential WBC count | Yes |
| 85009 | manual differential WBC count, buffy coat | Yes |
| 85013 | spun microhematocrit | Yes |
| 85014 | hematocrit (Hct) | Yes |
| 85018 | hemoglobin (Hbg) | Yes |
| 85025 | complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count | Yes |
| 85027 | complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) | Yes |
| 85032 | manual cell count (erythrocyte, leukocyte, or platelet) each | Yes |
| 85041 | red blood cell (RBC), automated | Yes |
| 85048 | leukocyte (WBC), automated | Yes |
| 85651 | Sedimentation rate, erythrocyte; non-automated | Yes |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) | Yes |
| 86689 | HTLV or HIV antibody, confirmatory test (eg, Western Blot) | Yes |
| 86694 | herpes simplex, non-specific type test | Yes |
| 86701 | HIV-1 | Yes |
| 86703 | HIV-1 and HIV-2, single result | Yes |
| 86780 | Treponema pallidum | Yes |
| 87070 | Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates | Yes |
| 87075 | any source, except blood, anaerobic with isolation and presumptive identification of isolates | Yes |
| 87076 | anaerobic isolate, additional methods required for definitive identification, each isolate | Yes |
| 87081 | Culture, presumptive, pathogenic organisms, screening only | Yes |
| 87086 | Culture, bacterial; quantitative colony count, urine | Yes |
| 87088 | with isolation and presumptive identification of each isolate, urine | Yes |
| 87101 | Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail | Yes |
| 87109 | Culture, mycoplasma, any source | Yes |
| 87110 | Culture, chlamydia, any source | Yes |
| 87205 | Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types | Yes |
| 87206 | fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types | Yes |
| 87207 | special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses) | Yes |
| 87210 | wet mount for infectious agents (eg, saline, India ink, KOH preps) | Yes |
| 87252 | Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect | Yes |
| 87254 | centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus | Yes |
| 87270 | Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis | Yes |
| 87274 | Herpes simplex virus type 1 | Yes |
| 87320 | Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis | Yes |
| 87340 | hepatitis B surface antigen (HBsAg) | Yes |
| 87390 | HIV-1 | Yes |
| 87391 | HIV-2 | Yes |
| 87449 | Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; multiple-step method, not otherwise specified, each organism | Yes |
| 87490 | Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique | Yes |
| 87491 | Chlamydia trachomatis, amplified probe technique | Yes |
| 87492 | Chlamydia trachomatis, quantification | Yes |
| 87510 | Gardnerella vaginalis, direct probe technique | Yes |
| 87511 | Gardnerella vaginalis, amplified probe technique | Yes |
| 87512 | Gardnerella vaginalis, quantification | Yes |
| 87528 | Herpes simplex virus, direct probe technique | Yes |
| 87529 | Herpes simplex virus, amplified probe technique | Yes |
| 87530 | Herpes simplex virus, quantification | Yes |
| 87531 | Herpes virus-6, direct probe technique | Yes |
| 87532 | Herpes virus-6, amplified probe technique | Yes |
| 87533 | Herpes virus-6, quantification | Yes |
| 87534 | HIV-1, direct probe technique | Yes |
| 87535 | HIV-1, reverse transcription and amplified probe technique | Yes |
| 87536 | HIV-1, reverse transcription and quantification | Yes |
| 87537 | HIV-2, direct probe technique | Yes |
| 87538 | HIV-2, reverse transcription and amplified probe technique | Yes |
| 87539 | HIV-2, reverse transcription and quantification | Yes |
| 87591 | Neisseria gonorrhoeae, amplified probe technique | Yes |
| 87623 | Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) | Yes |
| 87624 | Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) | Yes |
| 87625 | Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed | Yes |
| 87797 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism | Yes |
| 87798 | amplified probe technique, each organism | Yes |
| 87799 | quantification, each organism | Yes |
| 87806 | HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies | Yes |
| 87808 | Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis | Yes |
| 88141 | Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician | Yes |
| 88142 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manu supervision | Yes |
| 88143 | with manual screening and rescreening under physician supervision | Yes |
| 88160 | Cytopathology, smears, any other source; screening and interpretation | Yes |
| 88164 | Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision | Yes |
| 88165 | with manual screening and rescreening under physician supervision | Yes |
| 88166 | with manual screening and computer-assisted rescreening under physician supervision | Yes |
| 88167 | with manual screening and computer-assisted rescreening using cell selection and review under physician supervision | Yes |
| 88175 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision | Yes |
| 88199 | Unlisted cytopathology procedure | No |
| 88300 | Level I — Surgical pathology, gross examination only | Yes |
| 88302 | Level II — Surgical pathology, gross and microscopic examination | Yes |
| 88305 | Level IV — Surgical pathology, gross and microscopic examination | No |
| 88307 | Level V — Surgical pathology, gross and microscopic examination | No |
| 99000 | Handling and/or conveyance of specimen for transfer from the office to a laboratory | Yes |
* This service requires completion of the Consent for Sterilization form.
Allowable Procedure Codes for Services Provided to Members Receiving the Tuberculosis-Related Services-Only Benefit
Members may be enrolled in more than one limited benefit category. For example, a member may be enrolled in Family Planning Only Services and the TB-Related Services-Only Benefit. In this instance, providers should use the Family Planning Only Services Online Handbook in conjunction with the TB-Related Services-Only Online Handbook. (Wisconsin's EVS will indicate that these members are eligible for both limited benefit categories.)