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 two tables contain the procedure codes covered under Family Planning Only Services for men. 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.
| Office Visits for Males | ||
| 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 |
| 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 |
| Procedures and Supplies for Males | ||
| Procedure Code | Description | Requires allowable Contraceptive Management Code as Primary Diagnosis Code |
| A4267 | Contraceptive supply, condom, male, each |
Yes |
| J0696 | Injection, ceftriaxone sodium [Rocephin], per 250 mg |
Yes |
| Q0144 | Azithromycin dihydrate, oral, capsules/powder, 1 gram |
Yes |
| 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 |
| 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 |
Yes |
| 17111 | 15 or more lesions |
Yes |
| 55250* | Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) |
No |
| 55450* | Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) |
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 | ||
| 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 |
| 86592 | Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) |
Yes |
| 86689 | HTLV or HIV antibody, confirmatory test (eg, Western blot) |
Yes |
| 86701 | HIV-1 |
Yes |
| 86703 | HIV-1 and HIV-2, single result |
Yes |
| 86780 | Treponema pallidum |
Yes |
| 87205 | Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types |
Yes |
| 87206 | flourescent 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 |
| 87491 | Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique |
Yes |
| 87591 | Neisseria gonorrhoeae, amplified probe technique |
Yes |
| 87806 | HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies |
Yes |
| 99000 | Handling and/or conveyance of specimen for transfer from the office to a laboratory |
Yes |
| Anesthesia Services | ||
| 00921 | Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral |
No |
| * 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.) |