For Dates of Service Before January 1, 2009

Procedure Codes

Providers who submit claims for FPW 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 — newly covered procedure/service

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 — newly covered procedure/service

Yes

99402 approximately 30 minutes — newly covered procedure/service

Yes

99403 approximately 45 minutes — newly covered procedure/service

Yes

99404 approximately 60 minutes — newly covered procedure/service

Yes

Q3014

Telehealth originating site facility fee — newly covered procedure/service

No

S9445*

Patient education, not otherwise classified, non-physician provider, individual, per session — newly covered procedure/service

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

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) — newly covered procedure/service

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 — newly covered procedure/service

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 — newly covered procedure/service

No

46900 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical — newly covered procedure/service

No

46924 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) — newly covered procedure/service

No

56501 Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) — newly covered procedure/service

No

57061 Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) — newly covered procedure/service

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 — newly covered procedure/service

Yes

58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants — newly covered procedure/service

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 — newly covered procedure/service

Yes

71020 Radiologic examination, chest; stero, frontal — newly covered procedure/service

Yes

74740 Hysterosalpingography, radiological supervision and interpretation — newly covered procedure/service

Yes

90772 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
Diagnosis Code in
the V25 Series

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 — newly covered procedure/service

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) — newly covered procedure/service

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 — newly covered procedure/service

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 — newly covered procedure/service

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 — newly covered procedure/service

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 — newly covered procedure/service

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 — newly covered procedure/service

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 the FPW Program 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.)