Providers who submit claims for Family Planning Only Services on the UB-04 Claim Forms 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.
BadgerCare Plus covers additional services under the FPW. The following table contains the procedure codes.
| Office Visits | ||
| Procedure Code | Description | Requires Primary Diagnosis Code in the V25 Series |
| G0101 | Cervical or vaginal cancer screening; pelvic and clinical breast examination |
Yes |
| 99201 | Office or other outpatient visit for the evaluation and management of a new patient (10 min) |
Yes |
| 99202 | Office or other outpatient visit for the evaluation and management of a new patient (20 min) |
Yes |
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient (30 min) |
Yes |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient (45 min) |
Yes |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these three 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 (5 min) |
Yes |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient (10 min) |
Yes |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient (15 min) |
Yes |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient (25 min) |
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 appropriate immunization(s), 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 appropriate immunization(s), 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 |
| * Not covered with procedure codes 99384-99396 and 99401-99404. |
| Procedures and Supplies | ||||
| Procedure Code | Description |
Requires
Primary Diagnosis Code in the V25 Series |
||
| A4261 | Cervical cap for contraceptive use |
Yes |
||
| A4264 | Permanent implantable contraceptive intratubal occlusion device(s) and delivery |
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 |
||
| J0696 | Injection, ceftriaxone sodium [Rocephin], per 250 mg |
No |
||
| J1055 | Injection, medroxyprogesterone acetate for contraceptive use, 150 mg |
Yes |
||
| J1056 | Injection, medroxyprogesterone acetate/estradiol cypionate, 5 mg/25 mg |
Yes |
||
| J7300 | Intrauterine copper contraceptive |
Yes |
||
| J7302 | Levonorgestrel-releasing intrauterine contraceptive system, 52mg |
Yes |
||
| J7303 | Contraceptive supply, hormone containing vaginal ring, each |
Yes |
||
| J7304 | Contraceptive supply, hormone containing patch, each |
Yes |
||
| J7307 | Etonogestrel implant system (new HCPCS 010108) |
Yes |
||
| S4993 | Contraceptive pills for birth control |
Yes |
||
| 11975 | Insertion, implantable contraceptive capsules |
Yes |
||
| 11976 | Removal, implantable contraceptive capsules |
Yes |
||
| 11977 | Removal with reinsertion, implantable contraceptive capsules |
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 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 15 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 |
||
| 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 |
||
| 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 | Information is available for DOS before May 1, 2010. 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 |
||
| 58670 | Laparoscopy, surgical; with fulguration of oviducts (with or without transaction) |
Yes |
||
| 58671 | With occlusion of oviducts by device (e.g. band, clip or Falope ring) |
Yes |
||
| 71010 | Radiologic examination, chest; single view, frontal |
Yes |
||
| 71020 | Radiologic examination, chest; stero, frontal |
Yes |
||
| 74740 | Hysterosalpingography, radiological supervision and interpretation |
Yes |
||
| 96372 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular |
Yes |
||
| 99070 | Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) |
Yes |
||
| Colposcopy | ||||
| Procedure Code | Description |
Requires
Primary |
||
| 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 the endocervical curettage |
No |
||
| 57460 | With loop electrode biopsy(s) of the cervix |
No |
||
| 57461 | With loop electrode conization of the cervix |
No |
||
| Laboratory Services | ||
| Procedure Code | Description |
Requires
Primary Diagnosis Code in the V25 Series |
| 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 |
| 83907 |
Molecular diagnostics; lysis of cells prior to nucleic acid extraction (eg, stool specimens, paraffin embedded tissue) |
Yes |
| 84146 | Prolactin |
Yes |
| 84443 | Thyroid stimulating hormone (TSH) — newly covered procedure/service |
Yes |
| 84450 | Transferase; aspartate amino (AST) (SGOT) [Only used if patient has history of Mono] |
Yes |
| 84703 | Gonadotropin, chorionic (hCG); 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; qualitative (eg, VDRL, RPR, ART) |
Yes |
| 86689 | Antibody; 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 assay |
Yes |
| 86781 | Treponema pallidum, confirmatory test (eg, FTA-abs) |
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 isolates, 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 cytopathetic 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 enzyme immunoassay technique, 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 enzyme immunoassay technique 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, amplified probe technique |
Yes |
| 87536 | HIV-1, quantification |
Yes |
| 87537 | HIV-2, direct probe technique |
Yes |
| 87538 | HIV-2, amplified probe technique |
Yes |
| 87539 | HIV-2, quantification |
Yes |
| 87591 | Neisseria gonorrhoeae, amplified probe technique |
Yes |
| 87620 | Papillomavirus, human, direct probe technique (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] [to accompany human papillomavirus] 079.4) |
Yes |
| 87621 | Papillomavirus, human, amplified probe technique |
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 |
| 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 (List separately in addition to code for technical service) |
Yes |
| 88142 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician 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 physician's office to a laboratory |
Yes |
| Anesthesia Services | ||
| Procedure Code | Description |
Requires Primary Diagnosis Code in the V25 Series |
| 00851 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transaction |
Yes |
| 00952 | Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography |
Yes |
|
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 this attachment in conjunction with TB-Only publications. (When verifying enrollment for these women, Wisconsin's EVS indicates that they are eligible for both limited benefit categories.) |