Medicaid Family Planning Waiver
Reimbursable Services
The list of reimbursable family planning waiver services has been updated as of July 1, 2011. The following is a linked listing of the codes that are covered by the waiver. You may choose to download the complete list [90KB] and save the PDF file to your hard drive for future reference. Be sure to check this site periodically to see if the list has been updated.
Claims for extended family planning services must be submitted with the following specific procedure codes and diagnosis codes. All claims submitted for any other claims will be denied.
CPT CODE |
DESCRIPTION OF COVERED CODES |
99384FP |
Family Planning New/Established Visit |
99385FP |
|
99386FP |
|
99394FP |
|
99395FP |
|
99396FP |
|
99403FP |
Family Planning Counseling Visit |
99211FP |
Family Planning Supply Visit |
99070 |
Physician office supplies for reimbursement of permanent implants (see 58565) |
99201 |
Extended family planning services-new patient (treatment of STI) |
99211 |
Extended family planning services-established patient (Treatment of STI) |
J1055 |
Injection Medroxyprogesterone Acetate (Depo-Provera) |
J7300 |
Intrauterine Copper Device (Paraguard) |
J7302 |
Levonorgestrel-Releasing Intrauterine Device (Mirena) |
J7307 |
Etonogestrel implant system, including implant and supplies (Implanon) |
00840 |
Anesthesia For Intraperitoneal Procedures In Lower Abdomen Including Laparoscopy |
00851 |
Anesthesia for tubal ligation/transection |
11976 |
Removal of Implantable Contraceptive Capsules |
11980 |
Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) |
11981 |
Insertion, non-biodegradable drug delivery implant |
11982 |
Removal, non-biodegradable drug delivery implant |
11983 |
Removal with reinsertion, non-biodegradable drug delivery implant |
57170 |
Diaphragm or Cervical Cap fitting with instructions |
57452 |
Colposcopy of the cervix |
57454 |
Colposcopy with biopsy(s) of the cervix and endocervical curettage |
57460 |
Colposcopy with loop electrode biopsy(s) |
58300 |
Insertion of Intrauterine Device |
58301 |
Removal of Intrauterine Device |
58340 |
Catheterization and introduction of saline or contrast material for saline infusion for hysterosalpingography |
58565 |
Bilateral fallopian tube occlusion by permanent implants |
58600 |
Ligation or transection of fallopian tube(s) |
58615 |
Occlusion of fallopian tube(s) by device (e.g. band, clip, Falope ring) |
58670 |
Surgical laparoscopy, with fulguration of oviducts (with or without transection) |
58671 |
Surgical laparoscopy, with occlusion of oviducts by device (e.g. band, clip, or Falope ring) |
76856 |
Ultrasound of pelvis, nonobstetric (to check placement of intrauterine devices) |
76882 |
Ultrasound of extremity, limited, anatomic specific (to check for implantable contraceptive device) |
|
|
Laboratory Procedures |
|
81001 |
automated, with microscopy |
81002 |
non-automated, without microscopy |
81003 |
automated, without microscopy |
81005 |
Urinalysis; Qualitative or semiqualitative |
81007 |
Urinalysis; bacteriuria screen, by kit |
81015 |
Urinalysis; bacteriuria screen, microscopic only |
81025 |
Urine pregnancy test, by visual color comparison |
82947 |
Glucose; quantitative, blood |
84702 |
Gonadotropin, chorionic (hCG); quantitative |
84703 |
Gonadotropin, chorionic (hCG); qualitative |
85007 |
Blood count; manual differential WBC count |
85014 |
Hematocrit |
85018 |
Hemoglobin |
86255 |
Fluorescent antibody; screen, each antibody (HIV & Herpes) |
86382 |
Neutralization test, viral |
86403 |
Rubella screen (IgG) |
86580 |
Tuberculosis, intradermal |
86592 |
Syphilis test; qualitative (e.g., VDRL, RPR,ART) |
86593 |
Syphilis test; quantitative |
86689 |
HTLV or HIV antibody, confirmatory test (western blot) |
86694 |
Herpes simplex, non-specific type test |
86695 |
Herpes simplex, type I |
86701 |
HIV-1 |
86703 |
HIV-1 and HIV-2, single assay |
86706 |
Hepatitis B surface antibody (HBsAb) |
86707 |
Hepatitis Be antibody (HBeAb) |
86762 |
Rubella titer |
86780 |
Antibody; Treponema Pallidum (Syphilis Confirmatory) |
86803 |
Hepatitis C antibody |
87060 |
Throat culture |
87070 |
Culture, bacterial, definitive; any other source (GC) |
87075 |
Culture, bacterial, any source; anaerobic (isolation) |
87081 |
Culture, bacterial, screening only (GC) |
87086 |
Culture, bacterial, urine; quantitative, colony count |
87088 |
Culture, bacterial, urine; quantitative colony count, with isolation and presumptive identification of each isolate |
87110 |
Culture, chlamydia |
87164 |
Dark field examination, any source, includes specimen collection |
87205 |
Neisseria gonorrhoeae smear |
87206 |
Smear, primary source, with interpretation; (chlamydia) |
87210 |
Smear, primary source, wet mount isolation, with stain |
87252 |
Virus identification; tissue culture inoculation & observation |
87340 |
Hepatitis B surface antigen (HBsAg) |
87350 |
Hepatitis Be antigen (HBeAg) |
87480 |
Candida species, direct probe technique |
87481 |
Candida species, amplified probe technique |
87490 |
Chlamydia trachomatis, direct probe technique |
87491 |
Chlamydia trachomatis, amplified probe technique |
87510 |
Gardnerella vaginalis, direct probe technique |
87515 |
Hepatitis B virus, direct probe technique |
87516 |
Hepatitis B virus, amplified probe technique |
87520 |
Hepatitis C virus, direct probe technique |
87521 |
Hepatitis C virus, amplified probe technique |
87522 |
Hepatitis C virus, quantification |
87528 |
Herpes simplex virus, direct probe technique |
87529 |
Herpes simplex virus, amplified probe technique |
87590 |
Neisseria gonorrhoeae, direct probe technique |
87591 |
Neisseria gonorrhoeae, amplified probe technique |
87620 |
Papillomavirus, human, direct probe technique |
87621 |
Papillomavirus, human, amplified probe technique |
88141 |
Cytopathology, cervical or vaginal (any system) requiring physician interpretation |
88142 |
Cytopathology, cervical or vaginal (preservative fluid) under physician supervision |
88143 |
Cytopathology, cervical or vaginal with manual screen & re-screen under physician supervision |
88150 |
Cytopathology, slides, cervical or vaginal, manual screen under physician supervision |
88152 |
Cytopathology, slides, cervical or vaginal with manual screening and computer-assisted rescreen under physician supervision |
88153 |
Cytopathology, slides, with manual screen & re-screen under physician supervision |
88154 |
Cytopathology, slides with manual screen & computer-assisted re-screening using cell selection and review under physician supervision |
88155 |
Cytopathology, slides, cervical or vaginal, with definitive hormonal evaluation |
88164 |
Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening under physician supervision |
88165 |
Cytopathology. slides, cervical or vaginal (Bethesda System);with manual screen & re-screen under physician supervision |
88166 |
Cytopathology, slides, cervical or vaginal (Bethesda System), manual screen & computer-assisted re-screen under physician supervision |
88167 |
Cytopathology, slides, cervical or vaginal, (Bethesda System), using cell selection and review under physician supervision |
88174 |
Cytopathology, cervical or vaginal, (any reporting system), collected in preservative fluid, automated thin layer preparation, screen by automated system, under physician supervision |
88175 |
With screen by automated system and manual rescreening or review, under physician supervision |
88302 |
Level II surgical pathology, gross and microscopic (sterilization) |
88305 |
Level IV surgical pathology, gross and microscopic (colposcopy) |
|
|
HIV Counseling Codes |
|
99401 |
HIV counseling (pre-test) |
99402 |
HIV counseling (post-test) |
|
|
Diagnosis Codes to be used with family planning services |
|
V25.01 |
Prescription of oral contraceptives |
V25.02 |
Initiation of other contraceptive measures |
V25.03 |
Encounter for emergency contraceptive counseling and prescription |
V25.04 |
Counseling and instruction in natural family planning to avoid pregnancy |
V25.11 |
Encounter for insertion of IUD |
V25.12 |
Encounter for removal of IUD |
V25.13 |
Encounter for removal and replacement of IUD |
V25.2 |
Sterilization |
V25.41 |
Surveillance of previously prescribed contraceptive method-contraceptive pill |
V25.42 |
Surveillance of previously prescribed contraceptive method-IUD |
V25.43 |
Implantable subdermal contraceptive |
V25.5 |
Insertion of implantable subdermal contraceptive |
V72.31 |
Routine gynecological examination |
V72.32 |
Encounter for Pap cervical smear to confirm findings of recent normal smear following initial abnormal smear |
V76.2 |
Routine cervical Papanicolaou (Pap) smear |
|
|
Diagnosis codes to be used with sterilization procedures |
|
V25.2 |
Sterilization |
Diagnosis codes (must be used with colposcopies) |
|
622.0 |
Erosion and ectropion of cervix |
622.10 |
Dysplasia of cervix, unspecified |
622.11 |
Mild dysplasia of cervix |
622.12 |
Moderate dysplasia of cervix |
622.2 |
Leukoplakia of cervix (uteri) |
795.00 |
Abnormal glandular Papanicolou (Pap) smear of cervix |
795.01 |
Pap smear of cervix with atypical squamous cells of undetermined significance (ASC-US) |
795.02 |
Pap smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) |
795.03 |
Pap smear of cervix with low grade squamous intraepithelial lesion (SGSIL) |
795.04 |
Pap smear of cervix with high grade squamous intraepithelial lesion (HGSIL) |
795.05 |
Cervical high risk human papillomavirus (HPV) DNA test positive |
795.06 |
Pap smear of cervix with cytologic evidence of malignancy |
795.07 |
Satisfactory cervical smear but lacking transformation zone |
795.08 |
Unsatisfactory cervical cytology smear |
795.09 |
Other abnormal Pap smear of cervix and cervical HPV |
795.10 |
Abnormal glandular PAP smear of vagina |
795.11 |
Pap smear of vagina with atypical squamous cells of undetermined significance (ASC-US) |
795.12 |
Pap smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) |
795.13 |
Pap smear of vagina with low grade squamous intraepithelial lesion (SGSIL) |
795.14 |
Pap smear of vagina with high grade squamous intraepithelial lesion (HGSIL) |
795.15 |
Vaginal high risk human papillomavirus (HPV) DNA test positive |
795.16 |
Pap smear of vagina with cytologic evidence of malignancy |
795.18 |
Unsatisfactory vaginal cytology smear |
795.19 |
Other abnormal Pap smear of vagina and vaginal HPV |
|
|
Diagnosis codes must be used with lab procedures |
|
054.10 |
Genital herpes, unspecified |
054.11 |
Herpetic vulvovaginitis |
054.12 |
Herpetic ulceration of vulva |
078.10 |
Viral warts, unspecified |
078.11 |
Condyloma acuminatum |
078.88 |
Other specified diseases due to chlamydiae |
079.98 |
Unspecified chlamydial infection |
091.0 |
Genitial syphillis, primary |
091.2 |
Other primary syphilis |
092.0 |
Early syphilis, latent, serological relapse after treatment |
092.9 |
Early syphilis, latent, unspecified |
098.0 |
Acute gonococcal infection of the lower genitourinary tract |
098.10 |
Gonococcal infection (acute) of the upper genitourinary tract, site unspecified |
098.11 |
Gonococcal cystitis (acute) |
098.15 |
Gonococcal cervitis (acute) |
098.16 |
Gonococcal endometritis (acute) |
098.17 |
Gonococcal salpingitis, specified as acute |
099.41 |
Chlamydia trachomatis |
099.51 |
Other veneral diseases due to Chlamydia trachomatis-Pharynx |
099.52 |
Anus and rectum |
099.53 |
Lower genitourinary sites |
099.54 |
Other genitourinary sites |
099.56 |
Peritoneum |
099.8 |
Other specified venereal disease |
099.9 |
Venereal disease, unspecified |
112.1 |
Candidiasis of vulva and vagina |
131.00 |
Urogential trichomoniasis, unspecified |
131.01 |
Trichomonal vulvovaginitis |
131.02 |
Trichomonal urethritis |
622.0 |
Erosion and ectropion of cervix |
622.10 |
Dysplasia of cervix, unspecified |
622.11 |
Mild dysplasia of cervix |
622.12 |
Moderate dysplasia of cervix |
622.2 |
Leukoplakia of cervix (uteri) |
795.00 |
Abnormal glandular Papanicolou (Pap) smear of cervix |
795.01 |
Pap smear of cervix with atypical squamous cells of undetermined significance (ASC-US) |
795.02 |
Pap smear of cervix with atypical squamous cells of undetermined significance (ASC-US) |
795.03 |
Pap smear of cervix with low grade squamous intraepithelial lesion (SGSIL) |
795.04 |
Pap smear of cervix with high grade squamous intraepithelial lesion (HGSIL) |
795.05 |
Cervical high risk human papillomavirus (HPV) DNA test positive |
795.06 |
Pap smear of cervix with cytologic evidence of malignancy |
795.07 |
Satisfactory cervical smear but lacking transformation zone |
795.08 |
Unsatisfactory cervical cytology smear |
795.09 |
Other abnormal Pap smear of cervix and cervical HPV |
795.10 |
Abnormal glandular PAP smear of vagina |
795.11 |
Pap smear of vagina with atypical squamous cells of undetermined significance (ASC-US) |
795.12 |
Pap smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) |
795.13 |
Pap smear of vagina with low grade squamous intraepithelial lesion (SGSIL) |
795.14 |
Pap smear of vagina with high grade squamous intraepithelial lesion (HGSIL) |
795.15 |
Vaginal high risk human papillomavirus (HPV) DNA test positive |
795.16 |
Pap smear of vagina with cytologic evidence of malignancy |
795.18 |
Unsatisfactory vaginal cytology smear |
795.19 |
Other abnormal Pap smear of vagina and vaginal HPV |
V72.40 |
Pregnancy examination or test, pregnancy unconfirmed |
V72.41 |
Pregnancy examination or test, negative result |
V72.42 |
Pregnancy examination or test, positive results |
V76.2 |
Routine cervical Papanicolaou (Pap) smear |
V73.81 |
Human Papillomavirus (HPV) |
V73.88 |
Other specified chlamydial diseases |
|
|
Diagnosis Codes to be used for treatment of Sexually Transmitted Infections (STI) (procedure codes 99201 and 99211) |
|
099.9 |
Venereal disease, unspecified |
