Covered family planning services are identified by the allowable CPT and HCPCS procedures codes listed in the following table.
Evaluation and Management Services |
Procedure Codes |
Applicable Modifier |
|---|---|---|
Office or Other Outpatient Services |
99201-99215 |
|
Preventive Medicine Services |
99384-99387, 99394-99397 |
Medicine Services |
Procedure Codes |
Applicable Modifier |
|---|---|---|
Cervical or vaginal cancer screening; pelvic and clinical breast examination |
G0101 |
|
Immune Globulins |
90384-90386 |
|
Cardiovascular |
93000 |
|
93010 |
26 |
|
| Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | 96372 |
|
Special Services, Procedures and Reports |
99000 |
Surgery Services |
Procedure Codes |
Applicable Modifier |
|---|---|---|
Contraceptive implants |
11975-11977 |
|
Male Genital System |
54050 |
|
55250* |
|
|
55450* |
|
|
Female Genital System |
56440, 56501, 56605, 56606, 57061, 57170, 57452, 57454-57461 |
|
57500 |
||
58100-58120 |
|
|
58300-58301 |
|
|
58565*, 58600*, 58605*, 58615* |
|
|
59000 |
||
59840-59851** |
|
Anesthesia Services |
Procedure Codes |
Applicable Modifier |
|---|---|---|
Lower Abdomen |
00851 |
|
Perineum |
00921, 00952 |
Radiology Services |
Procedure Codes |
Applicable Modifier |
|---|---|---|
Chest |
71010-71022, 71030-71035 |
26, TC |
Spine and pelvis |
72170, 72190, 72200, 72202 |
26, TC |
Abdomen |
74000-74020 |
26, TC |
Gynecological and obstetrical |
74710 |
26, TC |
Abdomen and peritoneum |
76705 |
26, TC |
Pelvis |
76805 |
26 |
76815 |
26 |
|
76856 |
26 |
|
Extremities |
76885-76886 |
|
Ultrasonic guidance procedures |
76946, 76970 |
26 |
Laboratory Services |
Procedure Codes |
Applicable Modifier |
|---|---|---|
Organ or Disease Oriented Panels |
80050, 80055-80061 |
|
Urinalysis |
81000 |
|
81002, 81005, 81015, 81025 |
||
Chemistry |
82042, 82143, 82310, 82330, 82435, 82465, 82520, 82565, 82575, 82607, 82671-82677, 82728, 82746, 82947-82948 |
|
83020 |
26 |
|
83030-83033, 83045, 83518, 83540-83550, 83582-83593, 83655, 83718-83719, 83727, 83840, 83887-83890, 83892, 83894-83896, 83898, 83902, 84132, 84135, 84144-84146, 84295, 84315, 84403-84425, 84436-84445, 84478-84481, 84702-84703 |
||
Hematology and Coagulation |
85002-85007, 85009-85018, 85027-85041, 85060, 85651, 85660 |
|
Immunology |
86280, 86310, 86580, 86592-86593, 86631, 86689, 86694-86695, 86701, 86703, 86706, 86762-86765, 86787, 86800 |
|
Transfusion Medicine |
86850, 86900-86901 |
|
Microbiology |
87040, 87070, 87081, 87086, 87088, 87101, 87102, 87118, 87205, 87210, 87270, 87274, 87320, 87340, 87350, 87380, 87390-87391, 87449, 87485-87492, 87510-87517, 87528, 87530-87539, 87590-87591, 87620-87652, 87798-87799 |
|
Cytopathology |
88141-88152, 88155-88161, G0123 |
TC, 26 |
Cytogenetic Studies |
88261-88267, 88280 |
|
Other Procedures |
89300-89320 |
Supplies |
Procedure Codes |
Applicable Modifier |
|---|---|---|
Cervical cap for contraceptive use |
A4261 |
Permanent implantable contraceptive intratubal occlusion device(s) and delivery system |
A4264 |
Diaphragm for contraceptive use |
A4266 |
|
Contraceptive supply, condom, male, each |
A4267 |
|
Contraceptive supply, condom, female, each |
A4268 |
|
Contraceptive supply, spermicide (e.g., foam, gel), each |
A4269 |
|
Injection, ceftriaxone sodium, (Rocephin), per 250 mg |
J0696 |
|
Injection, medroxyprogesterone acetate for contraceptive use, 150 mg |
J1055 |
|
Intrauterine copper contraceptive |
J7300 |
|
Levonorgestrel-releasing intrauterine contraceptive system, 52 mg |
J7302 |
|
Contraceptive supply, hormone containing vaginal ring, each |
J7303 |
|
Contraceptive supply, hormone containing patch, each |
J7304 |
|
Etonogestrel (contraceptive) implant system, including implant and supplies |
J7307 |
|
Mifepristone, oral, 200 mg |
S0190*** |
|
Misoprostol, oral, 200 mcg |
S0191*** |
|
Contraceptive pills for birth control |
S4993 |
|
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) |
99070 |
|
* This services requires completion of the Consent for Sterilization form.
|
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